History and Physical Advice Tips Secrets

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Operative Note

PRE-OP DIAGNOSIS:

POST-OP DIAGNOSIS:

PROCEDURE: surgery performed.

SURGEONS: attending, residents, students who scrubbed.

FINDINGS: acutely inflamed gallbladder, 4-cm. diameter cyst, etc.

ANESTHESIA: general endotracheal (GETA), spinal, local, etc.

FLUIDS: amount and type (electrolytes, blood, etc. in cc or units).

ESTIMATED BLOOD LOSS: amount in cc.

DRAINS: type and location (T-tube in RUQ, etc.).

SPECIMENS: type sent to pathology (gallbladder and cystic duct, etc.).

COMPLICATIONS:

CONDITION: stable, extubated, transferred to recovery room, etc.

 

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Medical Notes:
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Discharge Summary
Off-Service Note
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Post-Partum Note
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Cardiology Progress Note and Consult

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