Term
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Definition
• Know the patients H&P, indication for operation
• Review anatomy, the steps of procedure and potential complications
• Pre-op: mark patient, update H&P; introduce yourself to scrub and circulatory staff, put your name and pager/cell on board
• Shoe covers and hair covers
• Arrive before patient is asleep
• Open your gloves/know your size; check whether or not you need to open your gown
• Help with IV, SCD’s, Foley, verify antibiotics and DVT prophylaxis
• Pad and position the patient with the team
• Discuss with anesthesia patient’s ideal BP, placement of NGT, intubation
• Get OR lights in appropriate position
• Put peddles and steps in appropriate locations
• Call attending
• Scrub and drape (be prepared before attending in position) |
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Term
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Definition
• Complete history & physical
• Labs (CBC, coags, chem 10, LFT’s, BNP)- notify if significant or changes
• EKG, CXR (selectively), U/A, other imaging studies
• NPO after midnight (hold tube feeds), maintenance IVF
• Antibiotics on call to OR; chlorhexidine scrub evening prior to OR
• Cefazolin if no viscus involved, Cefazolin and Flagyl for bowel, Vanco for vascular cases
• Anti-coagulation: usually hold ASA 7-10 days, Plavix 5-7 days, Coumadin 5 days, Heparin drip 4 hours (ask because may be different or wish to continue)
• Some services (ortho) want prophylactic anticoagulation held x 12 hours prior to OR -know who you are working with
• Bowel prep: know types, consent and start early
• Think about home meds: SSI, hold Lisinopril and oral hypoglycemics, give beta blocker
• Check for consult notes and recommendations
• Familiarize yourself with peri-op cardiac risk stratifications (cardiology clearance needed?)
• Call chief, attending after labs return, or note any discrepancies or if in any doubt |
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Term
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Definition
• Pre-op Dx:
• Procedure Planned:
• Labs:
• CXR/Pre-op imaging:
• EKG:
• Blood: type & screen, type & cross
• Orders: 1. NPO 2. Antibiotics 3. Skin Prep
• Permission: informed consent signed/on chart
• A/P: 45 y/o AAM with perforated sigmoid diverticulitis – To OR for sigmoid colectomy
– IV Cipro/Flagyl
– NPO/IVF (specify) |
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Term
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Definition
• MR#
• Date
• Anesthesiologist
• Anesthesia: name, type, noted problems
Medications (peri- operative antibiotics, stress steroids)
• cc to referring physicians/providers •
• Pre-opdiagnosis
• Post-opdiagnosis
• Procedure(s)performed
• AttendingSurgeon
• Fluids
• EBL
• Drains,packs, catheters: what type & where
• Surgeons/PA/NP/students present
• FB,grafts,implants: what & where placed
• Cultures:fromwhere?
• Specimens:including frozen sections
• Sponge, needle instrument count
• Findings
• Complications
• Indications
• Informedconsent
• DetailsofOperative Procedure: also detail what others need to know after the incision is closed |
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Term
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Definition
• MR #
• Providers present
• Indication
• Procedure
• Consent
• Description of the Procedure
• Complications |
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Term
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Definition
• Speak to accepting resident, floor, nurse, family
• Write post-op orders
– Review basic orders, pre-op orders, home medications, note po status/abx/DVT prophylaxis/drain & dressing care)
– Remember to think about head to toe prophylaxis: pain, nausea, itching, reflux, DVT, stool softeners, antibiotics, Beta blockade, insulin
– Write consults: PT/OT/SW/Nutrition/SLP
– Remember to call consults
• Ensure op note is written |
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Term
| Called to See Patient: Documentation |
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Definition
• Any major event, making an assessment or performing an intervention
• Called to see patient for ______
• Description of Event/Vitals/Exam
• Assessment
• Intervention/Plan |
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Term
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Definition
• Subjective:includesovernighteventsandpatient’s report of how they are currently feeling; flatus; pain
• Objective:vitalswithranges,Ins/Outs(bycategory), drains, PE, wound, labs, meds, radiology
• Assessment:onesentencetotietogether
– 80y/o WF POD #2 s/p right hemicolectomy doing well now with return of bowel function
• Plan:dependingoncomplexitythiscanbeadetailed plan by organ system or a list of things you want to do for the patient or by problem list.
• Remembereachdaytothinkaboutline/drains/tubes (are they still needed) consults, and disposition |
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Term
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Definition
• Date of admission
• Date of discharge
• Admission/discharge diagnosis
• Service
• Attending
• Primary referring provider
• Consults
• Procedures
• History and PE: PMH/PSH with dates
– Allergies
– Outpatient medications (with doses) – FH
– Social/sexual/OBGYN hx
• Procedures (with dates)
• Hospital course
• Discharge medications (list meds that were added or changed during admission)
• Discharge Condition: good, stable, fair, critical, guarded
• Disposition: to home, rehab, SNF
• Discharge Instructions: Activity/Diet/wound care/cast care etc.
• Follow up plans (include any tests scheduled for follow up) |
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