Surgery Documentation Guidelines

Last Updated 06/13/2018

PROGRESS NOTES

  1. Progress notes explains the treatment plan AND the thinking behind that plan.
  2. A well-crafted summary line is useful both to the writer and the reader.  In addition to age and gender:
    1. Surgical admission: hospital day, diagnosis, active issues.
    2. Postop admission: postop day, operation, indication, active issues.
    3. Trauma admission: post-injury day, bulleted list of injuries and management.
    4. Consultation: reason for consultation, primary service.
  3. Focus should be on the assessment and plan; emphasis should be on readability.
  • . Maximum length should be 1-2 screens.
  1. Bulleted lists are helpful.
  1. NEVER use “COPY FORWARD”
  • . Simply, “copy forward” is bad physicianship.
  1. It is an error-prone process: mistakes are propagated.
  2. It does not save time; it is more time-consuming to edit yesterday’s note than start fresh.
  1. To preserve summaries and details of the hospital course, please use the “Handoff” function in EPIC.
  2. Avoid lists of auto-populated data.
  • . There is no need to auto-populate medications, vitals, labs, etc., as nobody is going to use your note as a reference for clinical data.
  1. Because auto-populated data is rarely reviewed as it is written, auto-populate can lead to the “writing” of erroneous or problematic data that you have overlooked, e.g., a critical or spurious lab value, or a missed radiographic finding.
  1. Do not delete or ignore sections required for hospital compliance, e.g., DVT prophylaxis, lines, skin assessment, reason for hospitalization, etc.
  2. Language is important: be specific.  Write down diagnoses whenever possible.

 

HISTORY AND PHYSICAL

 

  1. The initial H&P is the best opportunity write an accurate story about the patient’s illness.
  2. Do not ignore the family history.
  3. Do not ignore the social history: you should address occupation/employment (premorbid functional status), family situation (disposition), and substance history (anesthesia risk).

 

OPERATIVE REPORT

 

  1. The “Procedure in Detail” should focus on what you did, and why you did it.
  2. Include details about DVT prophylaxis, antibiotics, and the operative time-out.