- Joined
- Aug 3, 2004
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Hey fellers/fellettes
Do y'all have a bare-bones skeleton for Pre-op notes that you use? The reason I ask is that I don't know if I'm doing enough/too much. Here's mine.
ID: 57 AAM c hx morbid obesity, cad, pvd, DM2 280-350 x20yr
CCx: Scheduled for L BKA.
MHx:___
SHx:___
Meds:___
SocHx:___
FHx:____
Allrg:____
ROS: Mainly CP, SOB, neuro Sx
Lab:
Imaging/EKG:
VS:
PE: mainly Nexk ROM, MP class, Heart, lung, quick neuro exam.
A/P: ASA4 needs BKA,
1.Pending Sx: blah blah blah reccs
Some input by the more experienced attendings and academic docs would be nice to help me shape my notes, although, I'd like to see what other residents are doing too.
Do y'all have a bare-bones skeleton for Pre-op notes that you use? The reason I ask is that I don't know if I'm doing enough/too much. Here's mine.
ID: 57 AAM c hx morbid obesity, cad, pvd, DM2 280-350 x20yr
CCx: Scheduled for L BKA.
MHx:___
SHx:___
Meds:___
SocHx:___
FHx:____
Allrg:____
ROS: Mainly CP, SOB, neuro Sx
Lab:
Imaging/EKG:
VS:
PE: mainly Nexk ROM, MP class, Heart, lung, quick neuro exam.
A/P: ASA4 needs BKA,
1.Pending Sx: blah blah blah reccs
Some input by the more experienced attendings and academic docs would be nice to help me shape my notes, although, I'd like to see what other residents are doing too.
