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).
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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