17 Questions
What best describes the purpose of medical documentation?
B and C
When is a procedure note used?
In minor procedures
What is the purpose of the Pre-operative H&P?
Ask a specific and targeted HPI (target around anesthesia and surgery)
When asking a patient about past medical history and surgeries for a pre-op H&P, what condition should you specifically ask about in regards to a personal/family hx? (best answer)
malignant hyperthermia
In the pre-operative physical exam, what do you want to include?
ALL of the above, including heart, lungs, abdomen, neuro, MSK
When it comes to lab results, you only document results that have recently been completed in the H&P.
True
Assessment in a Pre-Op Note - does it go under acute or chronic?
Pre-op diagnosis = Acute Pre-existing conditions that will need monitoring (DM2) = Chronic ASA score = Chronic Exploratory Laparotomy for SMO = Acute
What should be included in the pre-operative PLAN?
ALL of the above
What is placed in medical record IMMEDIATELY following procedure to suffice until dictated full operative note is complete?
Brief operative note
A brief post operative note should include information on the post-op diagnosis, blood product use, tourniquet use, drain use.
True
How do you start a post-operative order?
Admit to Attending/floor/service (not PACU)
How often should vital be taken for a post-operative patient outside of the PACU?
q4 hours
What is NOT included in a post-op note?
Discharge instructions
This is how you start the POST-OP SOAP NOTE Pt is POD #2 s/p appendectomy by Dr. Yang.
True
What note is used to document patient information in SOAP formation to specifically document any changes since last note?
post-op note
What hospital note includes the day by day hospital course?
Discharge Note
In the discharge summary, what is disposition?
Who will care for patient
Study Notes
Medical Documentation
- The primary purpose of medical documentation is to record and communicate patient information accurately and efficiently.
Procedure Notes
- A procedure note is used to document the details of a surgical procedure, including the procedure itself, anesthesia, and any complications.
Pre-Operative H&P
- The purpose of the Pre-operative History and Physical (H&P) is to assess a patient's overall health and identify any potential risks or complications related to surgery.
- The Pre-operative H&P includes a thorough review of the patient's medical history, including a detailed account of past medical conditions, surgeries, and medications.
Pre-Operative Physical Exam
- The pre-operative physical exam should include a thorough assessment of the patient's vital signs, including temperature, pulse, blood pressure, and respiratory rate.
- The exam should also include a review of the patient's medical history, including any prior surgeries or medical conditions.
Lab Results
- Only recent lab results are included in the H&P, as they are most relevant to the patient's current health status.
Assessment
- The assessment section of the Pre-Op Note falls under acute issues.
Pre-Operative Plan
- The pre-operative plan should include any necessary interventions, medications, or other treatments planned for the patient.
Post-Operative Notes
- A brief post-operative note should include information on the post-op diagnosis, blood product use, tourniquet use, and drain use.
- The operative note, including a detailed description of the procedure, is typically dictated by the surgeon and placed in the medical record immediately following the procedure.
Post-Operative Orders
- Post-operative orders should be started with "Post-Operative Day #1" or "Post-Operative Day #2", for example.
Vital Signs
- Vital signs should be taken for post-operative patients outside of the PACU at least every 4-6 hours.
SOAP Notes
- A SOAP note is used to document patient information in a standardized format, including subjective, objective, assessment, and plan.
Hospital Notes
- A hospital note, also known as a daily progress note, includes a day-by-day hospital course, documenting any changes or updates in the patient's condition.
Discharge Summary
- The discharge summary should include the patient's disposition, or the final outcome of their hospital stay.
Post-Operative SOAP Note
- A post-operative SOAP note should start with "Pt is POD # [insert number] s/p [insert procedure] by [insert surgeon's name]".
Test your knowledge on the importance and purpose of medical documentation in healthcare settings. Understand the significance of accurate and detailed medical records for patient care, legal protection, and billing purposes.
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