what is a post-op note?

[FractureFixer]

okay so i am freaking the F- out. I have to do a patient notes tomarrow morning on a patient that I surgerized today. What am i supposed to do??

PS. Third year f-ing sucks!

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[agranulocytosis]

take a picture of the patient with your phone, email it to yourself, print it out and put it in the chart. label it "see, payshent is cool".

 

[smq123]

okay so i am freaking the F- out. I have to do a patient notes tomarrow morning on a patient that I surgerized today. What am i supposed to do??

PS. Third year f-ing sucks!

There is a difference between a post-op note and a regular progress note.

If you "surgerized" the patient today, then likely the resident on night call wrote the post-op note. Post-op checks should be done 4-6 hours after the end of the operation.

When you go in and see the patient tomorrow, write a regular progress note. Note urine output, JP drain output, any nausea or vomiting, and whether or not the patient is tolerating the current diet (and note whatever diet that is - clear liquids, sips only, regular house diet, etc). Do a regular physical exam, listening to heart, lungs, etc. Check the incision, and note if it is c/d/i (clean/dry/intact). See if the patient's pain is reasonable for the size of his/her operation, or if it is out of proportion. There will be other things to check for, depending on what operation was done, but this should be enough to get you started.

 

[SouthernSurgeon]

okay so i am freaking the F- out. I have to do a patient notes tomarrow morning on a patient that I surgerized today. What am i supposed to do??

PS. Third year f-ing sucks!

Having to write a simple progress note hardly merits freaking out. It is a routine responsibility that you will have to do nearly every day of third year. SMQ outlined the basics.

 

[Winged Scapula]

When you go in and see the patient tomorrow, write a regular progress note. Note urine output, JP drain output, any nausea or vomiting, and whether or not the patient is tolerating the current diet (and note whatever diet that is - clear liquids, sips only, regular house diet, etc). Do a regular physical exam, listening to heart, lungs, etc. Check the incision, and note if it is c/d/i (clean/dry/intact). See if the patient's pain is reasonable for the size of his/her operation, or if it is out of proportion. There will be other things to check for, depending on what operation was done, but this should be enough to get you started.

To clarify: do not take the dressing down unless you have been told to. Just look to see if the dressing is intact and not heavily stained with blood or other bodily fluids. Most surgeons say dressing down in 48 hrs, but we had one who insisted on POD #5.

 

[Substance]

Third year does suck, I agree. It's essentially one big forced networking and anus-kissing gig, with maybe a few valuable medical traning sessions thrown in there. It's ad-hoc and schizophrenic. That being said...

...the post-op note is to determine how your patient is doing post-op. Duh.

Where I rotated, surgeons didn't like to spend a lot of time writing notes, unlike their medicine compatriots. Instead, they wanted to know if anything bad is happening after the surgery. Things the like to know are:

1. vitals: one of the things you'll be pimped on for sure are the causes of post operative fever, and when they are most likely to happen. Something like the "five Ws" or something...I'm not even sure if there's any evidence to support this little piece of surgical dogma, but you'll be asked it that's for sure.

2. ins/outs. Ins being fluids, oral intake. Outs being drains, urine, feces, NG, vomitus etc.

3. Any symptoms that the patient is complaining of like NV, wound pain, chest pain, etc. Always ask if they're farting. So important. Surgeons love to talk about things like ileus and obstructions. You'll get pimped on that heavy.

4. Regular physical exam: the legs(for DVT), the lungs, general fluid status and incision, essentially, with more attention given to anything else that the symptomatology may warrant. They'll ask you to record and do the rest but I've never encountered anything else that changed management by doing an entire exam(still do it though, if nothing but to appease your superiors). Poking on the abdomen after abdo surgery is a very mean thing to do, in my opinion.

5. Your plan of action given all of the above. Make sure to remember adequate analgesia and antinausea, and remember to try to get the patient up and around sooner rather than later. The last thing you want is someone to be newly bedridden and deconditioned. Also, investigate any concerning findings.

Now, that's all I can come up with for now. I hope it helps.

 

[45408]

To clarify: do not take the dressing down unless you have been told to. Just look to see if the dressing is intact and not heavily stained with blood or other bodily fluids. Most surgeons say dressing down in 48 hrs, but we had one who insisted on POD #5.

ugh, that dressing must look great on #5

 

[MJB]

Third year sucks? I think you may be certifiably insane.

I'll take this over sitting in lecture, sitting in a desk reading, etc....

 

[Winged Scapula]

ugh, that dressing must look great on #5

He insisted it was some Hopkins thing. There was so much BS practice that wasn't EBL (like the whole "can't shower with a JP in." Why?)

Either way, we'd get reamed by him if the student or intern took it off by mistake. It was certifiably insane.

 

[FractureFixer]

Thanks guys, I managed to survive, with all your help. It wasn't as hard as I thought and my residents were nicer than what everyone says (that they will yell if you do it wrong etc). I still think 3rd year sucks. All I do is follow my residents doing scut work (with 1-2 procedures etc) all the while azz kissing and trying not to look like a total tool (not sure if I succeeded). Doing this for 30+ hours of call makes me want to kill myself!

 

[MJB]

I need to retract my previous statement regarding "3rd year".

I've since learned it's not so much "3rd year" as it is what rotation you're on.

I'm on IM...and I've changed my mind. Thus far, IM doesn't excite me.

Dear Lord, please let these next 7.5 weeks go by VERY fast.

 

[FractureFixer]

I need to retract my previous statement regarding "3rd year".

I've since learned it's not so much "3rd year" as it is what rotation you're on.

I'm on IM...and I've changed my mind. Thus far, IM doesn't excite me.

Dear Lord, please let these next 7.5 weeks go by VERY fast.

7.5 on IM.......