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The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
The operative report is dictated right after a surgical procedure and later transcribed into the patient's record. The operative report includes preoperative and postoperative diagnoses, patient condition after surgery, all medications used in association with the procedure, pertinent medical history (Hx) , physical examination (PE), consent ...
Postoperative fever refers to an elevated body temperature (≥ 38.5 °C) occurring after a recent surgical procedure. Diagnosing the cause of postoperative fever can sometimes be challenging; while fever in this context may be benign, self-limited, or unrelated to the surgical procedure, it can also be indicative of a surgical complication, such as infection.
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery.
A post-anesthesia care unit (PACU) and sometimes referred to as post-anesthesia recovery or PAR, or simply recovery, is a part of hospitals, ambulatory care centers, and other medical facilities. Patients who received general anesthesia , regional anesthesia , or local anesthesia are transferred from the operating room suites to the recovery area.
Orthostatic vital signs are also taken after surgery. [7] A patient is considered to have orthostatic hypotension when the systolic blood pressure falls by more than 20 mm Hg, the diastolic blood pressure falls by more than 10 mm Hg, or the pulse rises by more than 20 beats per minute within 3 minutes of standing [5] [7]
After surgery, optimal pain management and infection control is important. Several studies have shown variable-significance positive effects when a multidisciplinary, multifactorial approach to elderly patient is followed during pre, peri and post-operative care. [5] [7]
Postoperative nausea and vomiting (PONV) is the phenomenon of nausea, vomiting, or retching experienced by a patient in the post-anesthesia care unit (PACU) or within 24 hours following a surgical procedure.