Lachiewicz and Thomason will generally do everything except the op note. With Moss or Wilson, they’ll have you do everything.
- •Brief Op Note: SURGERY-BRIEF OP NOTE before you leave the OR. Make sure you are listed as Primary surgeon (circulating RN can update).
- •SURGERY-DISCHARGE NOTE: serves as “AVS” for patients. Check box for “GYN major” and “GYN minor” auto-populates patient instructions.
- •Post-op orders: Admissions/transfers → Gen Surg orders → Orders for postoperative 4B. Walks you through nursing vitals, diet. Click “quit” for return to clinic pop-up.
- •Word processing orders: free text orders nurses see. To discharge, put in word processing order: “Please discharge to home when 4B discharge criteria are met.” Put another word processing order with your name and pager number or phone number.
- •Prescriptions: review and prescribe (to window) if not given at pre-op visit.
- •Op note: surgery tab → click on surgery in left hand → operative note → right click to edit. Note is empty — generally copy/paste from brief op note as start. Dr. Lachiewicz has dot phrases through CPRS booster (ask him).
- •If patient is being admitted: write delayed orders. NEW WARD ADMIT GEN SURG ORDERS → GSU OBS → Admit to 4b observation for 23-hr obs. For longer admission use GSU WARD. Under the orders tab, “Write Delayed Orders” and put in admission orders (vitals, diet, meds). Upon discharge, need discharge note. If >24 hr, also need discharge summary (see tab next to surgery tab).