Clinical Skills III Week 4 (Surgical Notes & Cases)

Why Document?

Keep a careful scientific record

Communicate with others

Obtain reimbursement

Assure quality of care

Assure continuum of care

Decrease medicolegal risk

Educate future clinicians

Protocol in Surgery

What are you doing?

Why are you doing it?

Where are you doing it?

When are you doing it?

Who is who in surgery?

Surgical Dx

A disease or syndrome that will require surgical intervention as part of the cure or tx or the definitive cure or tx.

Ex:

Dx: Appendicitis (treated by)

Tx: Appendectomy

Post-operative Unit

Aka - PACU.

Area usually in close proximity to operating suites, where pts are initially monitored and cared for placed following an operation or procedure until cleared to floor or unit; staffed by PACU RNs

Scheduled Surgery

CLASS 5 - Surgery that has been planned for and scheduled in advance

Usually for a known diagnosis, such as a hernia repair, hernioplasty;

Scheduled at the pt's and surgeon's convenience

Emergent

Surgery that has not been planned for, CLASS 1

To treat or manage an emergent diagnosis, such as an emergency appendectomy (likely class 3 ish)

Considered an "add-on" case, or fit into the OR schedule between non-emergent cases

Surgical Team

Attending surgeon

Fellow

Resident

PA/Medical student

Scrub RN, Surgical technician, RNFA

Circulating RN - documenting, get things you need (in charge of room)

Anesthesia Team

Anesthesiologist

CRNA (Certified Registered Nurse Anesthetist)

Anesthesia Resident

Physician Assistant (specializing in anesthesia)

Informed consent

H&P

Pre-operative testing

Informed consent - must include procedure/surgeon/assistant/risks/ benefits/alternatives discussed

H & P completed within 30 days (FULL) of procedure and updated on the day of surgery

Pre-operative testing, EKG, CXR, laboratory studies, CBC, PT/INR, Chemistries, including LFTs, RFTs (testing depends upon procedure and protocol)

Recovery Team

Post-Anesthesia Care Unit staffed by PACU RNs who routinely care for pts who are recovering from anesthesia and surgical procedures

Surgical H&P

H&P by CC & HPI just as in previous H & Ps, and similar or identical to surgical diagnosis; example:

"I have a hernia and need to have it fixed" x 3 months (what they understand they are having done)

If SOAP format: A:Sx dx /P:Sx plan

often respiratory, cardiac, general, and area of the surgery

Admission Orders **very important**

Admit: admitting physician, service/floor

Diagnosis: Umbilical hernia

Condition: usually one word, i.e., critical (AVOID "STABLE")

Vital signs: how often?? (timing important)

Activity: i.e., bedrest, out of bed, etc.

Allergies: medication allergies? Latex allergy?

Nursing: any nursing orders

Diet: what type??

Admission Orders (cont.)

Ins & Outs: IV fluids, PO fluids, NG tubes, foleys, drains, etc.

Medications: any meds that the pt needs-necessary to order them all

Labs: any labs, diagnostic tests, monitors

Procedures: Hernioplasty

Call House Officer/PA if: notify PA if x, y, z occurs w/ the pt (contact #, name/service/team)

Admission Orders (example)

Admit: Dr. Kinzel/Przybylski, PA-C; General Surgery

Diagnosis: Umbilical hernia

Condition: Good

Vital signs: VSS every 30 minutes x 2; then every 1 hr x 2; then per shift/protocol (know what this is)

Activity: Out of bed with assistance

Allergies: Pcn

Nursing: Review d/c instructions prior to d/c

Diet: NPO prior to sx; s/p sx ice chips advance to ?? as tolerated

Ins & Outs: IV NSS at 100mL/ hr; foley catheter to gravity

Medications: morphine 2mg IV every 30 min prn pain, zofran 4 mg IV every 4 hrs prn N/V, ?

Labs/Monitors: Routine monitoring; specifically labs that you are interested in: h/h; CBC; pt-ptt, etc.

Procedures: Hernioplasty

Preoperative Note

- Preoperative Dx

- Planned Sx/Procedure

- Consent Signed & on the chart, include risks and possible, reasonable complications (if appropriate: death/stroke)

- Labs, EKGs, CXRs, Type & Cross Orders, and other preop tests/studies

- Special preop orders

- Expected pt disposition

Preoperative Note (example)

07/15/2026

Preoperative Dx:Appendicitis

Planned Procedure:Appendectomy

Consent: Signed & on the chart, include risks and possible complications

Labs, EKGs, CXRs, Type & Cross, preop tests

Orders: NPO, NSS 100mL/hr IV, Ancef 1 gm IV ½ hr prior procedure

Post-op pt admission to PACU & then to med/surg floor

Procedure Note

(Often completed by the surgeon or their private PA)

Procedure:

Permit: procedure, risks & benefits, alternatives, pt agreed and understood

Indication:

Physician:

Description:

Complications:

Estimated Blood Loss:

Disposition:

Brief Operative Note **very important**

Preoperative Dx

Postoperative Dx (usually same as ^)

Procedure (type of surgery, what we did)

Surgeons/assistants

Anesthesia (type of anesthesia and delivery)

Operative findings

Estimated Blood Loss

Fluids (crystalloids and colliods)

Drains (can eliminate if none)

Specimens (should look JUST like nursing documentation)

Complications

Condition

**pt sees this note so choose vocab wisely (mass > tumor for example)

Post-op Notes

Preop Dx

Postop Dx

Procedure(s)

Surgeon(s)/Assistant(s)

Anesthesia

Intraoperative findings

Estimated Blood Loss (EBL) - don't say minimal

Urine output

IV Fluids

Specimens

Drains

Tubes and Lines

Implants (not detailed)

Complications

Disposition (icu, pacu, etc.)

Postoperative Note - SOAP format

Date/Post-op Day #:

Procedure:

S: pt c/os, RN comments, CHECK pt orientation

O: V/S, I/Os, Exam, Meds, Labs

A: Assessments based on data

P: Medication changes, labs, procedures, consults d/c, etc.

Notes vs. Orders

Note- a brief comment or condensed report

Order- instructions from a healthcare provider specifying pt tx and care

Case 1: Dr. Jones

45 y/o female college professor & triathlete w/ h/o GERD who c/o "R foot pain x 3 days" after slipping off a curb. X-rays show fx at base of 5th metatarsal bone. Surgical fixation of fx recommended by Dr. Kravitz for definitive tx.

Preoperative Dx: fx at base of 5th metatarsal bone

Planned Sx/Procedure: Surgical fixation of fx

Consent: Signed & on the chart, include risks and possible complications

Labs, EKGs, CXRs, Type & Cross Orders, and other preop tests/studies: Urine HCG

Special preop orders:

Expected pt disposition: PACU

Date/Post-op Day #: 0

Procedure:

S:

O:

A:

P:

Case 2: Mr. Gomez

67 y/o retired male postal worker w/ h/o DM & alcoholism c/o "coffee-ground emesis x 5 hrs." Admission to surgical intensive care unit recommended for management of pt.

Admit:

Diagnosis: LGIB

Condition:

Vital signs:

Activity: bedrest

Allergies:

Nursing: monitor further emesis, is it BRB/coffee ground?

Diet: NPO

Ins & Outs: NS, LR. Monitor all Outs: BM, emesis, urine output

Medications: give most meds, NG tube for crush meds. add PPI.

Labs: glucose, A1C, Hct, LFTs, CBC, coag studies

Call House Officer/PA if: notify PA if incr episodes of emesis, SBP

Case 3: Ms. O'Reilly

23 y/o female medical student w/no PMH presents to the ED w/ "RLQ pain x 2 days." +N/V/anorexia. LMP: 1 wk ago. Denies meds. NKDA. Last oral intake 10 hrs ago. ETOH socially 1-2 /wk, denies tob/drugs. PE:+RLQ pain, +McBurney's sign

Admit: floor bed

Diagnosis: Appendicitis

Condition: young, healthy, 2 days

Vital signs: if stable, Q4 hrs

Activity: no restrictions

Allergies: none

Nursing:

Diet: NPO

Ins & Outs: fluids - NS, LR. Monitor urine output

Medications: zofran or phenergan. if ruptured, then abx and hold on surgery.

Labs: pregnancy test, CBC diff

Imaging: CT with contrast (IV)

Procedures: potential surgery, appendectomy pending labs and imaging

Call House Officer/PA if:

Preoperative Dx: appendicitis

Postoperative Dx:

Procedure: laparoscopic appendectomy, possible open

Surgeons/Assistants:

Anesthesia: general anesthesia with endotracheal tube (ANYTHING MOUTH TO ANUS)

Operative findings:

Estimated Blood Loss:

Fluids:

Drains:

Specimens:

Complications: none

Condition: good

Case 4: Mr. Warsawa

55 y/o male truck driver w/ PMH hemorrhoids c/o "rectal pain & bleeding upon defecation x 6 weeks." Recent colonoscopy normal w/ neg bxs of excised polyps. Recommended surgery: hemorrhoidectomy by Dr. Eton.

- external hemhorrhoids (below dentate line)

- surgery (we actually wouldn't do surg for external though)

- LABS: PT/INR, CBC

- NPO

59 y/o male art teacher w/ PMH Fournier's gangrene, +MRSA, HTN presents to ED w/ "abscess R chin from shaving x 4 days." Meds: Norvasc 10 mg once daily. NKDA. Hosp/PSxHx: Debridement for Fournier's gangrene,

4 wk hospitalization for same.

PROCEDURE: INCISION & DRAINAGE

Procedure: INCISION & DRAINAGE right chin abscess

Permit:

Indication

Physician

Description

Complications:

Estimated Blood Loss

Disposition: home

Discharge Instructions:

Wound care?

Rxs? (always make follow-up appt or give name and phone number for patient to make an appt.) avoid narcotics

Follow-up appt? w/in the week

Return to Emergency Dept if...

Please adhere to the following recommendations: specific skin cleansers, soaps, w/u for DM, smoking, etc.