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SURGICAL DOCUMENTATION

SURGICAL HISTORY AND PHYSICAL EXAMINATIONIdentifying Data: patient's name, age, race, sex; referring physician.Chief Complaint: Reason given by patient for seeking surgical care; place reason in

"quotation marks."History of Present Illness (HPI): Describe the course of the patient's illness, including whenit began, character of the symptoms; pain onset (gradual or rapid), precise character of pain(constant, intermittent); other factors associated with pain (defecation, urination, eating,strenuous activities); location where the symptoms began; aggravating or alleviating factors.Vomiting (characteristics, appearance, frequency, associated pain). Change in bowel habits;

bleeding, character of blood, (clots, bright or dark red), trauma; recent weight loss oranorexia; other related diseases; past diagnostic testing.Past Medical History (PMH): past diseases. All previous surgeries and indications; datesand types of procedures; serious injuries, hospitalizations; significant medical problems;history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction; hernia,gallstones.Medications:Allergies: Penicillin: Codeine?Family History: Medical problems in relatives. Family history of colonic polyposis,carcinomas, multiple endocrine neoplasia (MEN syndrome).Social History: Alcohol, smoking, drug usage.Review, of Systems (ROS):General: Weight gain or loss; appetite loss, fever, fatigue, night sweats.Head: Headaches, seizures.Eyes: Visual changes, diplopia, eye pain.Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses.Respiratory: Cough, shortness of breath, sputum.

Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema.Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (blacktarry stools), hematochezia (bright red blood per rectum), constipation, bloody stool, changein bowel habit; hernia, hemorrhoids, gallstones.Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence,

prostate problems.Gynecological: Last menstrual period, breast masses.Skin: Easy bruising, bleeding tendencies.Lymphatics: Lymphadenopathy.

SURGICAL PHYSICAL EXAMINATIONVital Signs: Temperature, heart rate, respirations, blood pressure, weight.Head, Eyes, Ears, Nose, Throat (HEENT):Eyes: Pupils equally round and react to light and accommodation (PERRLA): extraocularmovements intact (EOMI);Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes.Chest: Equal expansion; rhonchi, crackles, breath sounds.Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6),

pulses (graded 0-2+).Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillarynodes.Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness,

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organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note(tympanic), costovertebral angle tenderness (CVAT), inguinal masses.Genitourinary: External lesions, hernias, scrotum, testicles, varicoceles.Extremities: Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial ulnar,femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial andfemoral pulses), Homan's sign (dorsiflexion of foot elicits calf tenderness).Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood;

prostate masses.Neurological: Mental status; gait, strength (graded 0-5); deep tendon reflexes.Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrs or history of cardiovascular disease), urine analysis (UA),liver function tests, PT/PTT.Assessment (Impression): Assign a number to each problem and discuss each problemseparately.Plan: Describe surgical plans including preoperative testing, laboratory studies, medications,antibiotics.

PREOPERATIVE NOTEPreoperative Diagnosis:Procedure Planned:Type of Anesthesia Planned:Laboratory Data: Electrolytes, BUN, creatinine, CBC, PT/PTT, UA, EKG, Chest X-ray;type and screen for blood or cross match if indicated; liver function tests, ABG.Risk Factors: Cardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional riskfactors.Consent: Document explanation to patient of risk and benefits of procedure, and document

patient's informed consent or guardian's consent and understanding of procedure.Allergies:Major Medical Problems:Medications:

BRIEF OPERATIVE NOTE(Written immediately after the procedure)Date of the Procedure:Preoperative Diagnosis:Postoperative Diagnosis:Procedure:Names of Surgeon and Assistant:Anesthesia:Estimated Blood Loss (EBL):

Fluids and Blood Products Administered During Procedure: Specimens: Pathology specimens, cultures, blood samples.

POSTOPERATIVE NOTESubjective: Mental status & patient's subjective condition; pain control.Vital Signs: Temperature, blood pressure, pulse, respirations.Physical Exam: Chest and lungs; inspection of wound and surgical dressings; conditions ofdrains; characteristics and volume of output of drains.Labs:

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Impression:Plan:

PROBLEM-ORIENTED PROGRESS NOTEProblem List: Postoperative day number, antibiotic day number if applicable. Hospital daynumber, hyperalimentation day number. List each surgical problem separately (status post-appendectomy, hypokalemia). Address each numbered problem daily in progress note.Subjective: Write how the patient feels in the patient's own words; and give observationsabout the patient.Objective: Vital signs; physical exam for each system; thorough examination and descriptionof wound. Condition of dressings; purulent drainage, granulation tissue, erythema; conditionof sutures, dehiscence. Amount and color of drainage, laboratory data.Assessment: Evaluate each numbered problem separately.Plan: For each numbered problem, discuss any additional orders, surgical plans. Discusschanges in drug regimen or plans for discharge or transfer. Discuss conclusions ofconsultants.

DISCHARGE SUMMARYPatient's Name:Chart Number:Date of Admission:Date of Discharge:Admitting Diagnosis:Discharge Diagnosis:Attending or Ward Team:Surgical Procedures, Diagnostic Tests, Invasive Procedures:Brief History & Pertinent Physical Examination & Laboratory Data: Describe the courseof the patient's disease up until the patient came to the hospital including physical exam &laboratory data.Hospital Course: Describe the course of the patient's illness while in the hospital; includeevaluation, treatment, outcome of treatment, and medications given while in the hospital.Discharge Condition: Describe improvement or deterioration in patient's condition.Disposition: Describe the situation to which the patient will be discharged (home, nursinghome), and person who will take care of patient.Discharged Medications: List medications and instructions.Discharged Instructions & Follow-up Care: Date of return for follow-up care at clinic;diet, exercise.Problem List: List all active and past problems.Copies: Send copies to attending physician, clinic, consultants and referring physician.