Christopher P. Coppola, Alfred P. Kennedy, Jr. and Ronald J. Scorpio (eds.)Pediatric Surgery2014Diagnosis and Treatment10.1007/978-3-319-04340-1_82
© Springer International Publishing Switzerland 2014
Note Templates
(1)
Department of Pediatric Surgery, Janet Weis Children’s Hospital, 100 N. Academy Av. MC 21-70, Danville, PA 17822, USA
1.
Admission orders
(a)
Admit
(b)
Admitting service/physician/location
(c)
Covering resident(s) and contact information
(d)
Diagnosis
(e)
Condition (stable, fair, poor, critical, moribund, etc.…)
(f)
Vital sign frequency (also neurologic checks, pulse checks, weights, body part diameters, pulse oximetry)
(g)
Continuous monitoring/telemetry needed
(h)
Activity (bed rest, out of bed to chair, ambulate, assistance needed, fall risk, seizure prophylaxis)
(i)
Allergies
(j)
Nursing procedures
(i)
Wound and dressing care/changes
(ii)
Parameters for which to call surgeon (temperature, pulse, blood pressure, respiratory rate, urine output, change in examination, function, or mental status)
(iii)
Tubes and drains (both placement and monitoring of output)
(iv)
Tubes/orifices which cannot be manipulated, any signs to post over bed
(v)
Compression hose and/or sequential compression devices
(k)
Diet or NPO orders
(l)
In/Out monitoring and frequency
(m)
Intravenous access and fluids
(n)
Medication
(i)
Scheduled medication
(ii)
Continuous infusions
(iii)
Symptomatic medication
(iv)
Deep venous thrombosis prophylaxis
(v)
Stress ulcer prophylaxis
(vi)
Home medications to stop/continue
(vii)
Sliding scale for insulin
(o)
Laboratory specimens to collect/process
(p)
Blood bank orders for type and cross or transfuse
(q)
Diagnostic imaging to obtain
(r)
Electrocardiogram
(s)
Services to consult
(t)
Respiratory therapy orders
(u)
Physical/occupational therapy orders
2.
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Preoperative note and checklist
(a)
Diagnosis
(b)
Planned Procedure(s)
(c)
Surgeon(s)
(d)
Consent form status
(e)
Anesthesia evaluation requested/accomplished
(f)
Allergies
(g)
Vital signs
(h)
Relevant laboratory values
(i)
Serum studies
(ii)
Evaluation of coagulation
(iii)
Urine
(iv)
Blood bank type and cross or type and hold
(i)
Relevant diagnostic imaging
(j)
Electrocardiogram and other cardiac studies
(k)
Evaluation of pulmonary function: pulmonary function test, arterial blood gas
(l)
NPO order status and timing
(m)
Intravenous fluids
(n)
Preoperative antibiotics
(o)
Bowel preparation
(p)
Medications to continue/hold for operation
(i)
Anticoagulation
(ii)
Cardiac medication
(iii)
Insulin
(q)
Skin preparation/bathing
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