13. Standard (Consult, Progress, Op) Note Templates and Ordersets

Standard Consult and Progress Note Templates:

  • Surgery Progress Note: To be used for daily progress notes on primary floor patients (post-op or pre-op)
    • .GENSURGPROGNOTEPOSTOP
    • .GENSURGPROGNOTEPREOP
  • Surgery Consult Progress Note: To be used for daily progress notes for active consult patients
    • .GENSURGCONSULTPROGNOTE
  • Surgery H&P/Consult Note: To be used for admission or consult notes on new surgical patients
    • .SURGERYHPANDCONSULTS --> CONSULT
    • Delete either “History and Physical” or “Consult” from heading depending on whether it is a consult note or admission note, respectively
  • CVC Consult Notes: To be used for CVC consult notes  
    • .SURGERYHPANDCONSULTS --> INSERT CVC CONSULT
    • .SURGERYHPANDCONSULTS --> REMOVE CVC CONSULT
  • Trauma H&P/Progress Notes: To be used for admission or progress notes on new trauma patients
    • .SURGERYHPANDCONSULTS --> TRAUMA H&P
    • .TRAUMAPROGRESSNOTE

Standard Op Note Templates:

  • Many attendings have op note templates that you can use for operative reports.  Ask sub-specialty fellows and pediatric surgery fellows if you have questions.
  • We have standard templates used across the division for g-tubes, g-buttons, tunneled CVC insertion, and port insertion.  Please be sure to use these note templates when writing op reports for these procedures.  To access them:

1).  Open up a new note.

2).  In the box that says “Insert SmartText” type IP STANDARD


3).  Choose from the standard op note templates the one that is most appropriate (be sure to distinguish between g tube (“long tube”) and g button.



 

Standard Ordersets:

We have standardized ordersets for a number of cases and medications.  Please be sure to use them where they apply. 

  • Pre-Op and Post-Op Ordersets
    • General Surgery Admission Orders
    • General Surgery Post-Op
    • Pediatric Surgery Ambulatory Orders (for outpatient cases)
    • Appendicitis:
      • Appendicitis Pre-Op Admission
      • Appendectomy Non-Perforated Post-Op
      • Appendectomy Perforated Post-Op
    • Line Insertion – General Surgery
    • General Surgery I&D of Abscess
    • G-Tube Placement—General Surgery (contains both pre and post-op phases)
    • Pyloric Stenosis:
      • Pyloric Stenosis – Pre-op
      • Pyloric Stenosis – Post-Op
    • Colorectal:
      • Pre-Op Colorectal Surgery
      • Colorectal – Post Op Surgery
      • Sacral Nerve Stimulator/EUA/Biopsy/Dilation
    • Pectus:
      • Pectus Bar Removal
      • Pectus Repair
    • Gastric Bypass
  • Other Colorectal Ordersets:


    • Colorectal Surgery Rectal Enema Administration
    • Hirschsprung Disease Rectal Irrigation
    • Bowel Prep Orders
  • ECMO:
    • ECMO Cannulation
    • ECMO Care
    • ECMO Conditional Blood Product Orders
    • ECMO Hemofiltration Orders
    • Exit to ECMO
  • Medications:
    • Acetaminophen IV
    • IBD/UC Pre- and Post-Op Steroid Orders
    • GI Surgery Prophylactic Antibiotics
    • Surgical Discharge Controlled Substance Prescriptions