History and Physical Advice Tips Secrets

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Pre Operative Note

PRE-OP DIAGNOSIS:

PROCEDURE: planned surgery.

LABS: CBC, chemistries, PT/PTT, urinalysis, etc.

CHEST X-RAY: note findings.

EKG: note findings.

BLOOD: not needed, type/screen or type/cross 2 units packed RBCs, etc.

ORDERS: NPO, preoperative antibiotics, skin or colon preps, etc.

CONSENT: signed and on chart (if so).

 

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Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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