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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 forms, surgeon′s orders, and identifies the anesthetist and anesthesia used. [2] [3]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
Jackson-Pratt Drain Trans man with two Jackson-Pratt drains after keyhole mastectomy. A Jackson-Pratt drain (also called a JP drain) is a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites.
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 information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the inguinal canal in the groin region. There are two different clusters of hernia: groin and ventral (abdominal) wall.
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Patients are counseled to expect some soreness but to expect to be ready to perform daily activities 1–2 days after surgery. [38] Patients undergoing postpartum tubal ligations will not be delayed in their discharge from the hospital after birth, and recovery is not significantly different from normal postpartum recovery. [39]
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