Preoperative Teaching

Patient does not have MRSA posting.
 
S: [What is your understanding of the planned procedure?]
[text name="variable_1"]
 
O:  
Planned procedure: [text name="procedure_name"]
Date of procedure: [text name="procedure_date"]
Location of procedure: JAMACIA PLAIN

[vitals]

STOP-BANG Questionnaire for Obstructive Sleep Apnea
[select name="Q1" value="no=0|YES=1"] <-- 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
[select name="Q2" value="no=0|YES=1"] <-- 2. Do you often feel TIRED, fatigued, or sleepy during daytime?
[select name="Q3" value="no=0|YES=1"] <-- 3. Has anyone OBSERVED you stop breathing during your sleep?
[select name="Q4" value="no=0|YES=1"] <-- 4. Do you have or are you being treated for high blood PRESSURE?
[select name="Q5" value="no=0|YES=1"] <-- 5. BMI more than 35?
[select name="Q6" value="no=0|YES=1"] <-- 6. AGE over 50 years old?
[select name="Q7" value="no=0|YES=1"] <-- 7. NECK circumference > 15.75 inches?
[select name="Q8" value="no=0|YES=1"] <-- 8. Male GENDER?

Score --> [calc memo="number" value="score0=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8)"] / 8
Interpretation --> [calc memo="result" value="score1=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8);score1>4?'High Risk for Obstructive Sleep Apnea. Further evaluation required, consider sleep study.':'Low Risk for Obstructive Sleep Apnea'"]
 
Allergies: [text name="allergies_1"]
 
Advanced Directive: [text name="advanced_directive"]
Patient has Living Will:  [select name="livingwill_1" value="no|yes"] 
HC Proxy: [select name="hcproxy_1" value="no|yes"] [text name="hcp_details"]
ACD is in current Medical Record: [select name="acdchart_1" value="no|yes"] [text name="acd_details"]
Patient would like to complete ACD: [select name="acdcomplete_1" value="no|yes"]
ADC information packet given: [select name="adcpacket_1" value="no|yes"]
Active Medications: See H&P for Medication Reconciliation Documentation
 
BASELINE:
Vision Impaired: [select name="vision_1" value="no|yes"] [text name="vision_details"]
Hearing Impaired: [select name="hearingimpaired_1" value="no|yes"] [text name="hearing_details"]
Dentures: [select name="dentures_1" value="no|yes"]
Prosthesis/Grafts/Implants/Shunts: [select name="implants_1" value="no|yes"] [text name="implant_details"]
Level of Consciousness:  A/O x 3
Physical Limitations: [select name="limitations_1" value="no|yes"] 
Decline in Mobility: [select name="mobility_1" value="no|yes"]
Emotional State: [text name="emotionalstate_details" default="stable"]
Nutrition:  Current Diet: [text name="diet_details" default="regular"]
Recent Weight Changes: [select name="weight_1" value="no|yes"] [text name="weight_details"]
Any Difficulty Swallowing: [select name="swallowing_1" value="no|yes"]
Abuse: Are you being hurt hit or frightened by anyone at home or in your life? [select name="abuse_1" value="no|yes"] [text name="abuse_details"]
Any signs of abuse: [select name="signsabuse_1" value="no|yes"] [text name="signsabuse_details"]
Current VNA services: [select name="vna_1" value="no|yes"] [text name="vna_details"]
 
Information was given to: [select name="information_1" value="patient|significant other"]
 
Limitations/Barriers to Learning:
Cognitive: [select name="lim_1" value="no|yes"]
Sensory/Physical: [select name="lim_2" value="no|yes"]
Language: [select name="lim_3" value="no|yes"]
Cultural/Religious: [select name="lim_4" value="no|yes"]
Motivational/Emotional: [select name="lim_5" value="no|yes"]
Age-Related: [select name="lim_6" value="no|yes"]
Financial: [select name="lim_7" value="no|yes"]
Physical/Psychological Ready to Learn: [select name="lim_8" value="no|yes"]
 
The following information was reviewed:
Procedure
Pre-operative lab tests
Preoperative medications
Pre-operative diet
Surgical scrub
Recovery room routine
[checkbox name="variable_1" value="IV's|Blood|Postop pain control|Pain Scale|PCA Pump|Cough and deep breathe|Chest PT/nebulizer|Oxygen|Activity|Diet progression|Venodynes|TEDS|Foley Catheter|NG Tube|Drains"]
Post-op Equipment: [text name="equipment_comments"]
Patient given written instructions, gave verbal consent to email information as well.
Preop teaching booklet/information sheet was given to patient.
Patient was given opportunity to ask questions.
 
DISCHARGE PLANNUNG:
It was explained to the patient that he/she may not drive the day of procedure. [select name="discharge_1" value="yes|no"] [text name="discharge1_details"]
Designated driver arranged: [select name="discharge_2" value="yes|no"] [text name="discharge2_details"]
Is someone available at home: [select name="discharge_3" value="yes|no"] [text name="discharge3_details"]
Observation stay expected: [select name="discharge_4" value="no|yes"]
Patient uses VA travel: [select name="discharge_5" value="no|yes"] [text name="discharge5_details"]
Patient uses VA shuttles: [select name="discharge_6" value="no|yes"] [text name="discharge6_details"]
 
A:  
Ready for surgery: [select name="ready_1" value="yes|no"]
Patient is able to verbalize instructions given. [select name="ready_2" value="yes|no"] [text name="ready2_details"]
Travel Arrangements needed: [select name="ready_3" value="no|yes"]
Anticipated difficulties with patient managing at home: [select name="ready_4" value="no|yes"] [text name="ready4_details"]
Postop VNA services anticipated: [select name="ready_5" value="no|yes"]
Other problems identified: [text name="ready6_details"]
 
P:  
Reinforced teaching as needed.
Patient educational goals were met.
Reinforcement needed in the following areas: [text name="reinforcement_details"]
Follow-up Clinic: [text name="followup_details"]
Patient does not have MRSA posting.

S: [What is your understanding of the planned procedure?]


O:
Planned procedure:
Date of procedure:
Location of procedure: JAMACIA PLAIN

[vitals]

STOP-BANG Questionnaire for Obstructive Sleep Apnea
<-- 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
<-- 2. Do you often feel TIRED, fatigued, or sleepy during daytime?
<-- 3. Has anyone OBSERVED you stop breathing during your sleep?
<-- 4. Do you have or are you being treated for high blood PRESSURE?
<-- 5. BMI more than 35?
<-- 6. AGE over 50 years old?
<-- 7. NECK circumference > 15.75 inches?
<-- 8. Male GENDER?

Score --> numberscore0=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8) / 8
Interpretation --> resultscore1=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8);score1>4?'High Risk for Obstructive Sleep Apnea. Further evaluation required, consider sleep study.':'Low Risk for Obstructive Sleep Apnea'

Allergies:

Advanced Directive:
Patient has Living Will:
HC Proxy:
ACD is in current Medical Record:
Patient would like to complete ACD:
ADC information packet given:
Active Medications: See H&P for Medication Reconciliation Documentation

BASELINE:
Vision Impaired:
Hearing Impaired:
Dentures:
Prosthesis/Grafts/Implants/Shunts:
Level of Consciousness: A/O x 3
Physical Limitations:
Decline in Mobility:
Emotional State:
Nutrition: Current Diet:
Recent Weight Changes:
Any Difficulty Swallowing:
Abuse: Are you being hurt hit or frightened by anyone at home or in your life?
Any signs of abuse:
Current VNA services:

Information was given to:

Limitations/Barriers to Learning:
Cognitive:
Sensory/Physical:
Language:
Cultural/Religious:
Motivational/Emotional:
Age-Related:
Financial:
Physical/Psychological Ready to Learn:

The following information was reviewed:
Procedure
Pre-operative lab tests
Preoperative medications
Pre-operative diet
Surgical scrub
Recovery room routine

Post-op Equipment:
Patient given written instructions, gave verbal consent to email information as well.
Preop teaching booklet/information sheet was given to patient.
Patient was given opportunity to ask questions.

DISCHARGE PLANNUNG:
It was explained to the patient that he/she may not drive the day of procedure.
Designated driver arranged:
Is someone available at home:
Observation stay expected:
Patient uses VA travel:
Patient uses VA shuttles:

A:
Ready for surgery:
Patient is able to verbalize instructions given.
Travel Arrangements needed:
Anticipated difficulties with patient managing at home:
Postop VNA services anticipated:
Other problems identified:

P:
Reinforced teaching as needed.
Patient educational goals were met.
Reinforcement needed in the following areas:
Follow-up Clinic:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.63, 74 form elements, 359 boilerplate words, 27 text boxes, 1 checkboxes, 44 drop downs, 2 calculations, 86 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: