Deck 11: Documenting Inpatient Care

Question 1

List several questions that should be answered daily for postoperative patients.

Answer 1

Any of the following: Is the patient the same, better, or worse? Is the patient getting adequate pain relief? Has bowel function returned? Can the activity level be advanced? Can the diet be advanced? Can any sutures, staples, tubes, or drains be removed? Is the patient having any fever, cough, shortness of breath, or difficulty breathing?

Question 2

A postoperative patient has been on a full liquid diet for the past 24 hours. He now has full bowel sounds and says he is hungry. Write an order for a change in diet.

Answer 2

Advance diet to regular diet as tolerated.

Question 3

List seven components of a procedure note.

Answer 3

Name of procedure; indication for procedure; consent; anesthesia; details of the procedure; findings; complications

Question 4

List at least five components of an operative note.

Question 5

List at least three risks associated with copying and pasting notes.

Question 6

List the five Ws that could be sources of postoperative fever.

Question 7

K.S. is a 50-year-old woman who presents for elective right carpal tunnel release. After reading the operative report shown in Figure 11-10, write an operative note.
Date of procedure:
Name of procedure:
Indication:
Surgeon:
Surgical assistant:
Anesthesia:
Pre-operative diagnosis:
Postoperative diagnosis:
Description:
Complications:
Disposition:

Question 8

D.M. is a 54-year-old man who was admitted for cirrhosis of the liver. An abdominal paracentesis was done earlier today, and the following procedure note was written. After reading the note, answer the following questions.
Name of procedure: abdominal paracentesis
Indication for procedure: ascites
Consent: form signed by patient before procedure
Anesthesia: local, total of 4 mL
Procedure: area was prepped and draped in usual sterile fashion. A 20-gauge needle was inserted and approximately 1,840 mL of fluid was removed. Fluid sent to lab for analy
-What additional information about consent should be documented in the procedure note?

Question 9

D.M. is a 54-year-old man who was admitted for cirrhosis of the liver. An abdominal paracentesis was done earlier today, and the following procedure note was written. After reading the note, answer the following questions.
Name of procedure: abdominal paracentesis
Indication for procedure: ascites
Consent: form signed by patient before procedure
Anesthesia: local, total of 4 mL
Procedure: area was prepped and draped in usual sterile fashion. A 20-gauge needle was inserted and approximately 1,840 mL of fluid was removed. Fluid sent to lab for analy
-After critically analyzing the note and comparing it to the one presented in the chapter, what additional information should be documented in the note?

Question 10

Refer to Figure 10-10, Admission H&P for C.H. After reviewing the H&P, answer the questions that follow.
-List at least three problems, symptoms, or complaints documented in the H&P that should be followed up when rounding on Mr. Hunter the day after his admission and documented in the Subjective portion of the daily visit note. State your rationale for including each one.

Question 11

Refer to Figure 10-10, Admission H&P for C.H. After reviewing the H&P, answer the questions that follow.
-List at least three findings that should be documented in the Objective portion of the daily visit note, and state your rationale for including each one.

Question 12

Refer to Figure 10-10, Admission H&P for C.H. After reviewing the H&P, answer the questions that follow.
-List at least three problems, symptoms, or complaints documented in the H&P that should be followed up when rounding on Mrs. McLaughlin the day after her admission and documented in the Subjective portion of the daily visit note. State your rationale for including each one.

Question 13

Refer to Figure 10-10, Admission H&P for C.H. After reviewing the H&P, answer the questions that follow.
-List at least three findings that should be documented in the Objective portion of the daily visit note, and state your rationale for including each one.

Question 14

These abbreviations were introduced in Chapter 11. Beside each, write the meaning as indicated by the content of this chapter.
-BMP:
-BP:
-CBC:
-CMS:
-EBL:
-EMR:
-H&P:
-HD:
-HPI:
-I&O:
-IS:
-JVD:
-PMH:
-POD:
-ROS:
-SOB:
-UTI:
-WBC: