surgery notes and orders

[DOindahouse]

how do u write daily notes for ortho patients, and how do u write post op notes for ortho, i dont want to look like a fool

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[powermd]

how do u write daily notes for ortho patients, and how do u write post op notes for ortho, i dont want to look like a fool

This is too funny..
Writing like a 14 year-old girl on AOL instant messenger is a good start.

 

[DOindahouse]

im being serious

 

[Celiac Plexus]

how do u write daily notes for ortho patients, and how do u write post op notes for ortho, i dont want to look like a fool

Just freestyle it. Dazzle them with some osteopathic manipulative medical terminology. Be creative. Remember, there is no "right way" to write a surgical note.

Seriously man, just wing it.

 

[DOindahouse]

you guys are bloody ******ed

 

[killahB]

ADC VAAN DIML (hope your familiar with this mnemonic- admit to, dx, condition, vitals, allergies, activity, nursing, diet, iVFs, meds, labs)
In the activity section, you have to specify the weight bearing status (NWB, WBAT, partial weight bearing etc) of the extremity, you usually write PT/OT consult , and Strict Ice/elevation

Meds- pain control with a narc, nausea control with zofran, abx coverage with ancef (or in an open fx- something more broad spectrum), start anticoagulating pod 1 with lovenox or coumadin, stool softener with colace or senokot. The rest is standard post op stuff

 

[killahB]

and as far as daily/post op notes
Check the neurovascular status
Cap refill
Sensation intact to light touch in the nerve distributions
are the most distal muscles working (EHL/TA/GS for LE, DIO/FDP, EPL, APB for UE)
usually write something like splint to LE c/d/i...

and for the plan, you generally won't go wrong with
Dispo planning,
Pain control
PT therapy

Heh, ortho notes are way easy

 

[hans19]

you guys are bloody ******ed

Don't you mean,
"u guyz r bloody ******ed."?

 

[powermd]

you guys are bloody ******ed

At least he has a sense of humor. You'll do well in ortho!