Surgical History and Physical Examination

Identifying Data: Patient's name, age, race, sex;
referring physician.

Chief Compliant: Reason given by patient for seeking
surgical care and the duration of the symptom.

History of Present Illness (HPI): Describe the course of
the patient's illness, including when it began, character of
the symptoms; pain onset (gradual or rapid), precise
character of pain (constant, intermittent, cramping,
stabbing, radiating); other factors associated with pain
(defecation, urination, eating, strenuous activities); location
where the symptoms began; aggravating or relieving
factors. Vomiting (color, character, blood, coffee-ground
emesis, frequency, associated pain). Change in bowel
habits; rectal bleeding, character of blood (clots, bright or
dark red), trauma; recent weight loss or anorexia; other
related diseases; past diagnostic testing.

Past Medical History (PMH): Previous operations and
indications; dates and types of procedures; serious
injuries, hospitalizations; diabetes, hypertension, peptic
ulcer disease, asthma, heart disease; hernia, gallstones
.
Medications: Aspirin, anticoagulants, hypertensive and
cardiac medications, diuretics.

Allergies: Penicillin, codeine, iodine.

Family History: Medical problems in relatives. Family
history of colon cancer, cardiovascular disease.

Social History: Alcohol, smoking, drug usage,
occupation, daily activity.

Review of Systems (ROS): General: Weight gain or loss; loss of appetite, fever, fatigue, night sweats. Activity level. HEENT: Headaches, seizures, sore throat, masses, dentures. Respiratory: Cough, sputum, hemoptysis, dyspnea on exertion, ability to walk up flight of stairs. Cardiovascular: Chest pain, orthopnea, claudication, extremity edema. Gastrointestinal: Dysphagia, vomiting, abdominal pain, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, change in bowel habits; hernia, hemorrhoids, gallstones. Genitourinary: Dysuria, hesitancy, hematuria, discharge; impotence, prostate problems, urinary frequency. Gynecological: Last menstrual period, gravida, para, abortions, length of regular cycle and periods, birth control. Skin: Easy bruising, bleeding tendencies. Neurological: Stroke, transient ischemic attacks, weakness.

Surgical Physical Examination
General appearance: Note whether the patient looks
“ill,” well, or malnourished.
Vital Signs: Temperature, respirations, heart rate, blood
pressure, weight.
Eyes: Pupils equally round and react to light (PERRL);
extraocular movements intact (EOMI). Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymphadenopathy; trachea midline. Chest: Equal expansion, dullness to percussion; rales, rhonchi, breath sounds.
Heart: Regular rate and rhythm (RRR), first and second heartsounds; murmurs (grade 1-6), pulses (graded 02+).
Breast: Skin retractions, erythema, tenderness, masses (mobile, fixed), nipple discharge, axillary or supraclavicular node enlargement.
Abdomen: Contour (flat, scaphoid, obese, distended), scars, bowel sounds, bruits, tenderness, masses, liver span; splenomegaly, guarding, rebound, percussion note (dull, tympanic), pulsatile masses, costovertebral angle tenderness (CVAT), abdominal hernias.
Genitourinary: Inguinal hernias, testicles, varicoceles; urethral discharge, varicocele.
Extremities: Skin condition, edema (grade 1-4+); cyanosis, clubbing, pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses). Grading of pulses: 0 = absent; 1+ weak; 2+ normal; 3+ very strong (arterial dilation).
Rectal Exam: Masses, tenderness, hemorrhoids, prostate masses; bimanual palpation, guaiac test for occult blood.
Neurological: Mental status, cranial nerves, gait,
strength (graded 0-5); tendon reflexes, sensory
testing. Laboratory Evaluation: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), glucose, liver function tests, INR/PTT, CBC with differential; X-rays, ECG (if older than 35 yrs or cardiovascular disease), urine analysis. Assessment (Impression): Assign a number to each problem and discuss each problem. Begin with most important problem and rank in order. Plan: Discuss surgical plans for each numbered problem, including preoperative testing, laboratory studies, medications, antibiotics, endoscopy.

Preoperative Preparation of the Surgical Patient
1. Review the patient's history and physical examination, and write a preoperative note assessing the patient's overall condition and operative risk.
2. Preoperative laboratory evaluation: Electrolytes, BUN, creatinine, INR/PTT, CBC, platelet count, UA, ABG, pulmonary function test. Chest x-ray (>35 yrs old), EKG (if older then 35 yrs old or if cardiovascular disease). Type and cross for an appropriate number of units of blood. No screening laboratory tests are required in the healthy patient.
3. Skin preparation: Patient to shower and scrub the operative site with germicidal soap (Hibiclens) on the night before surgery. On the day of surgery, hair should be removed with an electric clipper or shaved just prior to operation.
4. Prophylactic antibiotics or endocarditis prophylaxis if indicated.
5. Preoperative incentive spirometry on the evening prior to surgery may be indicated for patients with pulmonary disease.
6. Thromboembolic prophylaxis should be provided for selected, high-risk patients.
7. Diet: NPO after midnight.
8. IV and monitoring lines: At least one 18-gauge IV for initiation of anesthesia. Arterial catheter and pulmonary artery catheters (Swan-Ganz) if indicated. Patient to void on call to operating room.
9. Medications. Preoperative sedation as ordered by anesthesiologist. Maintenance medications to be given the morning of surgery with a sip of water. Diabetics should receive one half of their usual AM insulin dose, and an insulin drip should be initiated with hourly glucose monitoring.
10. Bowel preparation Bowel preparation is required for upper or lower GI tract procedures.
Antibiotic Preparation for Colonic Surgery
Mechanical Prep: Day 1: Clear liquid diet, laxative (milk of magnesia 30 cc or magnesium citrate 250 cc), tap water or Fleet enemas until clear. Day 2: Clear liquid diet, NPO, laxative. Day 3: Operation.
Whole Gut Lavage: Polyethylene glycol electrolyte
solution (GoLytely). Day 1: 2 liters PO or per nasogastric tube over 5 hours. Clear liquid diet. Day 2: Operation.
Oral Antibiotic Prep: One day prior to surgery, after mechanical or whole gut lavage, give neomycin 1 gm and erythromycin 250 mg at 1 p.m., 2 p.m., 11 p.m.
11. Preoperative IV antibiotics: Initiate preoperatively and give one dose during operation and one dose of antibiotic postoperatively. Cefotetan (Cefotan), 1 gm IV q12h, for bowel flora, or cefazolin (Ancef), 1 gm IVPB q8h x 3 doses, for clean procedures.
12. Anticoagulants: Discontinue Coumadin 5 days preop and check PT; stop IV heparin 6 hours prior to surgery.

Admitting and Preoperative Orders
Admit to: Ward, ICU, or preoperative room.
Diagnosis: Intended operation and indication.
Condition: Stable
Vital Signs: Frequency of vital signs; input and output
recording; neurological or vascular checks. Notify physician if blood pressure <90/60, >160/110; pulse >110; pulse <60; temperature >101.5; urine output <35 cc/h for >2 hours; respiratory rate >30.
Activity: Bed rest or ambulation; bathroom privileges.
Allergies: No known allergies
Diet: NPO
IV Orders: D5 1/2 NS at 100 cc/hour.
Oxygen: 6 L/min by nasal canula.
Drains: Foley catheter to closed drainage. Nasogastric
tube at low intermittent suction. Other drains, tubes,
dressing changes. Orders for irrigation of tubes.
Medications: Antibiotics to be initiated immediately preoperatively; additional dose during operation and 1 dose of antibiotic postoperatively. Cefotetan (Cefotan), 1 gm IV q12h, for bowel flora, or cefazolin (Ancef) 1 gm IVPB q8h x 3 doses;) for clean procedures.
Labs and Special X-Rays: Electrolytes, BUN, creatinine, INR/PTT, CBC, platelet count, UA, ABG, pulmonary function tests. Chest x-ray (if >35 yrs old), EKG (if older then 35 yrs old or if cardiovascular disease). Type and cross for an appropriate number of units of blood.

Preoperative Note
Preoperative Diagnosis:
Procedure Planned:
Type of Anesthesia Planned:
Laboratory Data: Electrolytes, BUN, creatinine, CBC,
INR/PTT, UA, EKG, chest x-ray; type and screen for
blood or cross match if indicated; liver function tests,
ABG.
Risk Factors: Cardiovascular, pulmonary, hepatic, renal,
coagulopathic, nutritional risk factors.
American Surgical Association (ASA) grading of
surgical risk: 1= normal; 2= mild systemic disease; 3=
severe systemic disease; 4= disease with major threat to
life; 5= not expected to survive.
Consent: Document explanation to patient of risks and
benefits of the procedure and alternative treatments.
Document patient's or guardian's informed consent and
understanding of the procedure. Obtain signed consent
form.
Allergies:
Major Medical Problems:
Medications:
Special Requirements: Signed blood transfusion
consent form; documentation that breast procedure
patients have been given an information brochure.

Brief Operative Note
This note should be written in chart immediately after the surgical procedure.
Date of the Procedure:
Preoperative Diagnosis:
Postoperative Diagnosis:
Procedure:
Operative Findings:
Names of Surgeon and Assistants:
Anesthesia: General endotracheal, spinal, epidural,
regional or local.
Estimated Blood Loss (EBL):
Fluids and Blood Products Administered During
Procedure:
Urine output:
Specimens: Pathology specimens, cultures, blood
samples.
Intraoperative X-rays:
Drains:
Condition of Patient: Stable

Operative Report
This full report should be dictated at the conclusion of the
surgical procedure.
Identifying Data: Name of patient, medical record
number; name of dictating physician, date of dictation.
Attending Surgeon and Service:
Date of Procedure:
Preoperative Diagnosis:
Postoperative Diagnosis:
Procedure Performed:
Names of Surgeon and Assistants:
Type of Anesthesia Used:
Estimated Blood Loss (EBL):
Fluid and Blood Products Administered During
Operation:
Specimens: Pathology, cultures, blood samples.
Drains and Tubes Placed:
Complications:
Consultations Intraoperatively:
Indications for Surgery: Brief history of patient and
indications for surgery.
Findings: Describe gross findings and frozen section
results relayed to operating room.
Description of Operation: Position of patient; skin prep
and draping; location and types of incisions; details of
procedure from beginning to end,including description of
surgical findings, both normal and abnormal.
Intraoperative studies or x-rays; hemostatic and closure techniques; dressings applied. Needle and sponge counts as reported by operative nurse. Patient’s condition and disposition. Send copies of report to surgeons and referring physicians.
Postoperative Check
A postoperative check should be completed on the evening after surgery. This check is similar to a daily progress note.
Example Postoperative Check
Date/time:
Postoperative Check
Subjective: Note any patient complaints, and note the adequacy of pain relief.
Objective:
 General appearance:
 Vitals: Maximum temperature in the last 24 hours (Tmax), current temperature, pulse, respiratory      rate, blood pressure.
 Urine Output: If urine output is less than 30 cc per hour, more fluids should be infused if the patient  is hypovolemic.
Physical Exam:
Chest and lungs:
Abdomen:
Wound Examination: The wound should be examined for excessive drainage or bleeding, skin necrosis, condition of drains. 
Drainage Volume: Note the volume and characteristics of drainage from Jackson-Pratt drain or other drains.
Labs: Post-operative hematocrit value and other labs. 
Assessment and Plan: Assess the patient’s overall condition and status of wound. Comment on abnormal labs, and discuss treatment and discharge plans.

Postoperative Orders
1. Transfer: From recovery room to surgical ward when stable.
2. Vital Signs: q4h, I&O q4h x 24h.
3. Activity: Bed rest; ambulate in 6-8 hours if appropriate. Incentive spirometer q1h while awake.
4. Diet: NPO x 8h, then sips of water. Advance from clear liquids to regular diet as tolerated.
5. IV Fluids: IV D5 LR or D5 1/2 NS at 125 cc/h (KCL, 20 mEq/L if indicated), Foley to gravity.
6. Medications:
 Cefazolin (Ancef) 1 gm IVPB q8h x 3 doses; if indicated for prophylaxis in clean cases OR Cefotetan (Cefotan) 1 gm IV q12h x 2 doses for clean
contaminated cases.
 Meperidine (Demerol) 50 mg IV/IM q3-4h prn pain Hydroxyzine (Vistaril) 25-50 mg IV/IM q3-4h prn nausea OR 
Prochlorperazine (Compazine) 10 mg IV/IM q4-6h prn
nausea or suppository q 4h prn.
7. Laboratory Evaluation: CBC, SMA7, chest x-ray in AM if indicated.

Postoperative Surgical Management
I. Postoperative day number 1
A. Assess the patient’s level of pain, lungs, cardiac status, flatulence, and bowel movement. Examine for distension, tenderness, bowel sounds; wound drainage, bleeding from incision.
B. Discontinue IV infusion when taking adequate PO fluids. Discontinue Foley catheter, and use in-andout catheterization for urinary retention.
C. Ambulate as tolerated; incentive spirometer, hematocrit and hemoglobin. D. Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h
prn pain. E. Colace 100 mg PO bid. F. Consider prophylaxis for deep vein thrombosis.

II. Postoperative day number 2
A. If passing gas or if bowel movement, advance to regular diet unless bowel resection.
B. Laxatives: Dulcolax suppository prn or Fleet enema prn or milk of magnesia, 30 cc PO prn constipation.

III. Postoperative day number 3-7
A. Check pathology report.
B. Remove staples and place steri-strips.
C. Consider discharge home on appropriate medications; follow up in 1-2 weeks for removal of sutures.
D. Write discharge orders (including prescriptions) in
AM; arrange for home health care if indicated. Dictate discharge summary and send copy to surgeon and referring physician.

Surgical Progress Note
Surgical progress notes are written in “SOAP” format.
Surgical Progress Note
Date/Time:
  Post-operative Day Number:
Problem List: Antibiotic day number and hyperalimentation day number if applicable. List each surgical problem separately (eg, status-post appendectomy, hypokalemia).
Subjective: Describe how the patient feels in the patient's own words, and give observations about the patient. Indicate any new patient complaints, note the adequacy of pain relief, and passing of flatus or bowel movements. Type of food the patient is tolerating (eg, nothing, clear liquids, regular diet).
Objective:
Vital Signs: Maximum temperature (Tmax) over the past 24 hours. Current temperature, vital signs. Intake and Output: Volume of oral and intravenous fluids, volume of urine, stools, drains, and nasogastric output.
Physical Exam:
  General appearance: Alert, ambulating.
  Heart: Regular rate and rhythm, no murmurs.
  Chest: Clear to auscultation.
  Abdomen: Bowel sounds present, soft, nontender.
  Wound Condition: Comment on the wound condition (eg, clean and dry, good granulation,        serosanguinous drainage). Condition of dressings, purulent drainage, granulation tissue, erythema;    condition of sutures, dehiscence. Amount and color of drainage
  Lab results: White count, hematocrit, and electrolytes, chest x-ray
Assessment and Plan: Evaluate each numbered problem separately. Note the patient's general condition (eg, improving), pertinent developments, and plans (eg, advance diet to regular, chest xray). For each numbered problem, discuss any additional orders and plans for discharge or transfer.

Procedure Note
A procedure note should be written in the chart when a procedure is performed. Procedure notes are brief operative notes.
Procedure Note
Date and time:
 Procedure:
Indications: 
Patient Consent: Document that the indications, risks and alternatives to the procedure were explained to the patient. Note that the patient was given the opportunity to ask questions and that the patient consented to the procedure in writing. 
Lab tests: Electrolytes, INR, CBC Anesthesia: Local with 2% lidocaine 
Description of Procedure: Briefly describe the procedure, including sterile prep, anesthesia method, patient position, devices used, anatomic location of procedure, and outcome.
Complications and Estimated Blood Loss (EBL):
Disposition: Describe how the patient tolerated the procedure.
Specimens: Describe any specimens obtained and laboratory tests which were ordered.

Discharge Note
The discharge note should be written in the patient’s chart prior to discharge.
Discharge Note
Date/time:
Diagnoses: 
Treatment: Briefly describe treatment provided during hospitalization, including surgical procedures and antibiotic therapy. 
Studies Performed: Electrocardiograms, CT scans.
Discharge Medications: 
Follow-up Arrangements:
Discharge Summary
Patient's Name:
Chart Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Name of Attending or Ward Service:
Surgical Procedures, Diagnostic Tests, Invasive
Procedures:
Brief History and Pertinent Physical Examination and
Laboratory Data: Describe the course of the patient’s
disease up to the time the patient came to the hospital,
and describe the physical exam and pertinent laboratory
data on admission.
Hospital Course: Briefly describe the course of the
patient's illness while in the hospital, including evaluation,
operation, outcome of the operation, and medications
given while in the hospital.
Discharged Condition: Describe improvement or
deterioration of the patient’s condition.
Disposition: Describe the situation to which the patient
will be discharged (home, nursing home) and the person
who will provide care.
Discharged Medications: List medications and
instructions and write prescriptions.
Discharged Instructions and Follow-up Care: Date of
return for follow-up care at clinic; diet, exercise
instructions.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, consultants
and referring physician.

Prescription Writing
• Patient’s name:
• Date:
• Drug name, dosage form, dose, route, frequency (include concentration for oral liquids or mg strength for oral solids): Amoxicillin 125mg/5mL 5 mL PO tid
• Quantity to dispense: mL for oral liquids, # of oral solids
• Refills: If appropriate
• Signature