PrincipalComponents of Postoperative Orders

Principal Components of Postoperative Orders

• Diagnosis (or diagnoses) and surgical procedure
• Condition
• Allergies
• Instructions for monitoring vital signs
• Acti~ity and positioning
• Diet
• Medications , If
• Intravenous (IV) fluids
‘. Wound care
• Parameters for notification of physician or dentist
• Special instructions (e.g., ice packs, lip protection
hygfene instructions)

ed for; if they are not, a search must’ be made to find  them. If necessary, intraoral gauze packs should be placed for hemostasis, and the packs should have long ends thattrail out of the mouth for easy retrieval. . Nurses (under the supervision of ahesthesiologists)  make many of the immediate postoperative decisions inthe postanesthesia care unit. However, the dentist should write postoperative orders immediately after the completion
of surgery to ensure that any special instructions can be initiated in the postanesthesia care unit. Postoperative orders should include statements of the diagnosis, procedure performed, patient allergies, and general
condition of the patient after surgery. Nursing actions, such as Vital-sign monitoring, wound care, and medication administration schedule, should be clearly spelled out. The patient’s diet, activity level, bed positioning, and allowable personal hygiene should be delineated. Finally, parameters
should be outlined that, if breached, make immediate notification
of the dentist or physidan mandatory, An outline
for postoperative orders is listed in Box 31-2;’ a sample of
postoperative orders is shown in Fig. 31-11.
Shortly after the surgical procedure is completed, a
brief operative note should be placed in the ‘patient’s
record. This note is usually in a relatively standard format
that includes listing the preoperative and postoperative
diagnoses, the names of the procedures performed during
surgery, the name or names of the surgeon or surgeons”
the type. of anesthesia, the placement of any drains, the
estimated blood loss, and whether any specimens were
sent for pathologic examination. The hospital staff uses
this note to quickly learn general information about the
operative procedure. In addition, .before leaving the operating suite a full
report of the operation should be dictated, using the designated format of the facility at which the surgery was performed. The general outlines and examples of a brief  operative note and transcribed operative report are
shown in Boxes 31-3 and 31-4 and in Fig. 31-12. Patients generally remain in the postanesthesia care unituntil they are sufficiently alert, unlikely to injure themselves, and their vital signs are stable within acceptable limits.
An anesthesiologis t usually makes the decision about discharge to a hospital room or home, unless it is specifiedthat the dentist will make that decision. The discharged  patient should be placed directly under the care of a competent adult and not be allowed to go home unescorted.
Hospital rounds (i.e. patient visits) give the surgeon the opportunity to check the patient’s postoperative recovery personally and to revise orders as necessary. U nstable hospitalized patients require frequent visits; stable
,patients are u sually seen twice a day during the first



week after surgery and once daily thereafter. Each patient visit by the surgeon warrants a brief notation (i.e., progress note) in the record, that documents the patient’s progress and ~ny new plans for further care. Kates are usually written using a record format that Includes a brief description
of how the patient is progressing subject’ and objectively, an assessment of the patient’s condition, and a plan for further care (SOAP). Figure 31-13 shows a typical postoperative progress notation in the SOAP format. .
Discharge planning should begin as soon as the surgical procedure is completed and includes making arrangements for any necessary patient education  such as oral hygiene, wound care, and diet-ary instructions  In addition, the patient should be told of acceptable activitv levels and plans for follow-up office visits. Necessary prescriptions for medications should be provided, as well as instructions on how to contact the appropriate physician or dentist should problems arise. A written discharge note
should tie included in the progress note section of themedical record (Fig. 31-14 and Box 31-5).

BOX 31-3

Common Format for Recording Brief Operative Note

• Preoperative diagnosis
• Postoperative diagnosis’
• Procedure
• Srgeon or surgeons

BOX. 31-4

Common Format for Dictating Operative Note

• State that operative note is being dictated
• State patient’s mime, spelling out last ‘name
.State patient’s medical record (hospital) number

BOX 31-15

L:i Complete a standard SOAP pru~r”~s note and
include the following under P (plans) section:
r: Deposition (to where and with whom patient will be
f” Listof medications that the patient is prescribed Or
instructed to take, including drug name, dosing regimen,
and instructions for use
[: Dietary instructions
r: Activity instructions
LC Hygiene instructions
r~ Follow-up appointment

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