Orthopedic Inpatient Protocols: A Guide to Orthopedic Inpatient Rounding
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About this ebook
Information is included to provide comprehensive patient care from admission to discharge, with sections dedicated to SOAP notes, daily rounding, medical complications, neurological exams, complex regional pain syndrome, and treatment options.
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Important Notes
This book should be used only as a general guide for providers of inpatient orthopedic care. Different hospitals and attending surgeons may vary in regards to specific protocols and medication formularies. Please check with your attending to be sure that the content of this book meets their specific standards of care.
SOAP Note
When rounding, notes written in the patient’s chart may be written in the SOAP note format:
S: Patient subjective findings (pain, SOB, CP, etc.)
O: Patient objective data (Vital signs, lab data, Is & Os, physical exam findings, etc.)
A: Assessment (POD# and surgical procedure, medical issues/conditions, other injuries, etc.)
P: Plan (PT, WBS, medications, DVT prophylaxis, NPO for OR today, etc.)
Daily Rounding
Print All Patient Lists
Organize and prioritize lists
Service patient vs. consult patient
New admissions
POD#
Planned discharge day
Note all injuries and procedures
Note all laboratory, radiology and diagnostic study results