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Patient Name MR Number DOB PowerPoint Presentation
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Patient Name MR Number DOB

Patient Name MR Number DOB

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Patient Name MR Number DOB

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  1. Surgery Patient Name MR Number DOB • Op Note: • Look in your pocket. There should be a Maxwell’s in there. Follow the format given to you. • Things to Know: • Surgeons are to the point—they want no more and no less info than is needed to take care of the Pt. • PATs are pre-op physical exams performed in the Surgical Admitting Center: be thorough and quick. • Your job will often consist only of retracting and cutting sutures. Become adept with steady hands. • Practice your knots so you can be a star when you get to suture something. • Always carry an energy bar or food in your lab coat pocket (a different pocket from your hemoccult supplies). • Pee BEFORE going to the OR. It is bad form to scrub out routinely for bathroom breaks. • It is always better to ask before touching/doing anything if you are not sure! • Divide up the cases the day before they are scheduled. You should know about the case and the patient before you get to the OR. • Always be in the OR waiting and ready when the attending arrives. • Take advantage of procedure opportunities! • No matter how much you are scolded and how tired you may be, remain a human being. That way you will still have friends after surgery. Date Time General Surgery Daily/Progress Note—MS III S: 24 hour events… the nurses’ observations may be helpful. Pt. subjective assessment of N/V/F/C, pain, wound, SOB, bowel activity, all per the patient. O: Vitals: Tmax / Tcurrent / bp / hr / resp / O2 sats/accucheck Vent settings: I/O: last 8hr- ‘in” (PO, IV)/ “outs” (urine, stool) previous 24hr- ‘in” (PO, IV)/ “outs” (urine, stool) Labs: Meds: Exam: GEN: HEENT: CV: PULM: ABD: EXT: NEURO: WOUND: LINES: A/P: __ y/o male/female with PMHx of ___ now with ______ (name the problem) s/p (status-post name the type of surgery performed) _____, post-op day ___ (the day of the operation is post-op day 0). 1.       CV 2.       HEME 3.       PULM 4.       GI 5.       RENAL 6.       WOUND 7.       ID 8.       NEURO/PSYCH 9.       FEN (fluids/electrolytes/nutrition) 10. Disposition • List by problem for floor patients. • List systems for ICU/MICU patients. • Be concise and direct. Do not say “consider” or “suggest” • List each problem and your plan to “fix” it. • Books: • Surgery Recall (for answers to everyday pimp questions) or Advanced Surgery Recall (for aspiring surgeons) • Surgical Attending Rounds (helpful when studying for oral exams) • Principles of Surgery, Greenfield (to look up specifics)