PREOPERATIVE PREOPERATIVE PREPARATION, PREPARATION,

OBSERVATION AND OBSERVATION AND DOCUMENTATION OF THE DOCUMENTATION OF THE

PATIENTSPATIENTSPATIENTSPATIENTSDR. JÁNOS MÁRTON DR. JÁNOS MÁRTON

READERREADER

DEPT. OF SURGERYDEPT. OF SURGERY

UNIVERSTIY OF SZEGEDUNIVERSTIY OF SZEGED

PREOPERATIVE ASSESSMENT

The operation is a central act of surgical care, but the outcome of surgical treatment is

tremendously enhanced by accurate preoperative assessment and

careful preoperative preparation.careful preoperative preparation.

Optimal preparation of the patient depends on factors relating to the patient`s

illness,physical condition,

related medical conditions,current surgical diagnosis

HISTORYPHYSICAL EXAMINATION

LABORATORY, RADIOGRAPHIC andELECTROCARDIOGRAPHIC EXAMINATIONS

ENDOSCOPIC EXAMINATIONSAll the foregoing tests are

subject to errors of interpretation, and subject to errors of interpretation, and the surgeon should be aware of such errors

and understand the sensitivity and specificity

of each test in the setting in which it is being used.

PSYCHOLOGICAL PREPARATIONPatient approach an operation

with considerable anxiety and fear, which is reasonable.

The patient needs to be told preoperatively what can be expected postoperatively,

whether he will have a nasogastric tube in place,if there is to be a tracheostomy and colostomy, if there is to be a tracheostomy and colostomy,

it will be temporary or permanent, and whether an extremity

will be immobilised or amputated.The patient should be told to expect

postoperative pain and that appropriate analgesic medication is available

but that he may have to ask for it.

THE OPERATIVE CONSENTThe patient has the right to know

the diagnosis of his illness, the prognosis,the nature of a proposed operation, what it is intended to accomplish,

the possibility of failure, the benefits, the risk in term of mortality and complications the risk in term of mortality and complications

and the alternative means of treatment available.The best practice of medicine and surgery (and the best defense against a lawsuit)

lies in developing a good relationship with the patient and his family and in open discussion

about the possible consequences of the surgery, which must be weighted against the expected benefits.

Amputation 1652Amputation 1652

AbbreviationAbbreviationss

Chief Complaint or Chief Complaint or Chief Concern (CC)Chief Concern (CC)

History of Present History of Present Illness (HPI)Illness (HPI)

Past Medical History Past Medical History (PMH)(PMH)Past Medical History Past Medical History (PMH)(PMH)

Past Surgical History Past Surgical History (PSH)(PSH)

Medications (MEDS) Medications (MEDS)

Allergies/Reactions Allergies/Reactions (All/RXNs)(All/RXNs)

Social History (SH) Social History (SH)

AbbAbbrreveviiations II.ations II.

Family History (FH)Family History (FH)

Obstetrical History Obstetrical History (where appropriate)(where appropriate)

Review of Systems Review of Systems (ROS) (ROS) (ROS) (ROS)

Physical Exam Physical Exam

Lab Results, Radiologic Lab Results, Radiologic Studies, EKG Studies, EKG Interpretation, Etc.Interpretation, Etc.

Problem list Problem list

ASSESSMENT/PLANASSESSMENT/PLAN

ItIt serves several purposesserves several purposes

It is an important It is an important reference documentreference document a a patient's historypatient's history and and exam findingsexam findings at the at the time of admission. time of admission. time of admission. time of admission.

PresentationPresentation

This information This information should be presented should be presented in a in a logical fashionlogical fashionthat prominently that prominently features all datafeatures all datafeatures all datafeatures all dataimmediately relevant immediately relevant to the to the patient's patient's conditioncondition. .

Benefits in medical educationBenefits in medical education

It allows students It allows students demonstrate their demonstrate their ability ability to accumulate historical to accumulate historical and examination based and examination based information examination information examination information examination information examination based informationbased information, make , make use of their medical fund use of their medical fund of knowledge, and derive of knowledge, and derive a a logical planlogical plan of attack. of attack.

Balanced judgementBalanced judgement

Knowing Knowing what to what to includeinclude and and what to what to leave outleave out will be will be largely dependent on largely dependent on experienceexperience and your and your experienceexperience and your and your understanding of understanding of illnessillness and and pathophysiology. pathophysiology.

You can recognize what you You can recognize what you know!know!

If you were If you were unaware unaware that chest pain is that chest pain is commonly associated commonly associated with coronary artery with coronary artery diseasedisease, you would , you would diseasedisease, you would , you would be unlikely to mention be unlikely to mention other coronary riskother coronary risk--factorsfactors when writing when writing the history. the history.

Don’t worry……Don’t worry……

Until you gain Until you gain experienceexperience, your , your writewrite--ups will be ups will be somewhat somewhat poorly poorly focusedfocused. Not to worry; . Not to worry; focusedfocused. Not to worry; . Not to worry; this will this will change with change with time and exposuretime and exposure. .

Why to keep records?Why to keep records?

Helps in medical decisionsHelps in medical decisions(is the size of a lymph node or nodule (is the size of a lymph node or nodule increasing with time?)increasing with time?)

Helps to share responsibility with the Helps to share responsibility with the Helps to share responsibility with the Helps to share responsibility with the patientpatient

Legal obligation.Legal obligation.

Protects the patient as well as doctor Protects the patient as well as doctor in front of the courtin front of the court

Has economic benefitsHas economic benefits

Useful to produce health statisticsUseful to produce health statistics

Provides epidemiological dataProvides epidemiological dataProvides epidemiological dataProvides epidemiological data

Assists practice managementAssists practice management

Useful in QI activitiesUseful in QI activities

Is a communication toolIs a communication tool

TypesTypes

According to the methodAccording to the method;;

––Source orientedSource oriented

––Problem orientedProblem oriented

PSOAPPSOAPPProblemroblem–– Everything the patient reports and doctor’s Everything the patient reports and doctor’s

findings which are regarded as problemsfindings which are regarded as problems

SSubjectiveubjective–– History of the problem; what the patient History of the problem; what the patient

feels or thinks about the problemfeels or thinks about the problemfeels or thinks about the problemfeels or thinks about the problem

OObjectivebjective–– Doctors findings related with the problemDoctors findings related with the problem

AAssessmentssessment–– Evaluation of the problem; the diff. Evaluation of the problem; the diff.

diagnosisdiagnosis

PPlanlan–– Prescription, consultation, advice, control Prescription, consultation, advice, control

Which data are we recording in Which data are we recording in practice?practice?

Chief Complaint or Chief Chief Complaint or Chief Concern (CC)Concern (CC)

One sentence that One sentence that covers the dominant covers the dominant reason(s) for reason(s) for hospitalizationhospitalization....

whywhy patientpatient herehere----

use patient's use patient's own own words words

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

THIS IS THE THIS IS THE DESCRIPTION DESCRIPTION OF OF THE PATIENT’S THE PATIENT’S ILLNESS AS TOLD ILLNESS AS TOLD BY THE BY THE PATIENTPATIENT, , BY THE BY THE PATIENTPATIENT, , FAMILYFAMILY, , OLD OLD CHARTCHART OR A OR A COMBINATION OF COMBINATION OF THESE.THESE.

History of Present IllnessHistory of Present Illness

Physician asks Physician asks questions to questions to discussingdiscussing the the discussingdiscussing the the detailsdetails of the of the chief complaint.chief complaint.

History of Present Illness answers History of Present Illness answers questions of ..questions of ..

WhenWhen the problem the problem began, began, whatwhat and and wherewhere the the symptoms are, symptoms are, symptoms are, symptoms are, what makes the what makes the symptoms symptoms worse worse or or betterbetter..

History of Present IllnessHistory of Present Illness

Ask about the Ask about the naturenature of the of the symptoms (for symptoms (for painpain, is it , is it sharpsharp or or painpain, is it , is it sharpsharp or or dulldull, , localizedlocalized or or generalizedgeneralized). ).