《外科英文病历（从入院－手术－出院）》.docVIP

Hospital Charts Paperwork and Protocols From admission through surgery in the O.R. or clinic to discharge Patient Admission ASU vs Overnight ? Overnight pre-op (rare) – Long distance – Pre-op compliance – Evaluation and testing ? ASU with post-op admission – Post-op monitoring – Post-op complications – Nursing supervision ? ASU or Day surgery, no admission – Compliant and relatively healthy patient – Relatively minimal surgery (??) Patient Admission- Preliminary Steps ? Financial responsibility – approved by third party ? Legal guardianship – mandatory if over 18 years and incompetent ? Complete Informed Consent – usually within 1 week of surgery ? Scheduling – O.R. time – Provide ASA risk level, O.R. time needed – Admitting office for bed or other scheduling needs ? Preadmission labs, HP ? Dental Treatment Plan, at least a general plan Medical Risk Assessment ? ASA I - Healthy individual ? ASA II – Mild systemic disease – Mild controlled HTN ? ASA II – Severe systemic disease – IDDM ? ASA IV – Incapacitating systemic disease – Cardiomyopathy ? ASA V – Moribund patient – Terminal leukemia ? E – designation with any of the above categories for emergent care necessary Hospital Chartwork Components ? Admission note ? Admission orders ? Progress notes ? Consents ? Pre-operative note ? Pre-operative orders  Hospital Chartwork Components ? Operative note ? Dictated Operative Report ? Post-op progress notes ? Post-op orders ? Discharge Note ? Discharge Orders ? Dictated Discharge Summary  Admission Paperwork ? Admission Note ? Admission Orders ? Dental Database ? Consent ? History and Physical (HP) ? Lab work, CXR, EKG  HP  HP  HP  HP Admission Note ? Admit to Dental Service for Dr. Jolly ? S (subjective) – Identify patient and condition (eg: 25 WM) – Chief Complaint (CC) – History of Present Illness (HPI) – Past Medical History (PMH) – Past Surgical / Anesthetic History (PSH / PAH) – Family History (FH) – Soci