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The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. [1] The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. [1]
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
However, it is an important component of the SOAP note as well. [13] Vital signs and measurements, such as weight. Findings from physical examinations, including basic systems of cardiac and respiratory, the affected systems, possible involvement of other systems, pertinent normal findings and abnormalities. The following areas should be included:
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.
Surgical planning is the preoperative method of pre-visualising a surgical intervention, in order to predefine the surgical steps and furthermore the bone segment navigation in the context of computer-assisted surgery. [1] The surgical planning is most important in neurosurgery and oral and maxillofacial surgery.
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.
The field of minimally invasive surgery has spawned another set of words, such as arthroscopic or laparoscopic surgery. These take the same form as above; an arthroscope is a device which allows the inside of the joint to be seen.
Strong for Surgery (S4S) is a public health campaign and quality improvement (QI) initiative developed and launched by the University of Washington in Washington State in 2012. [1] Strong for Surgery was developed by the Comparative Effectiveness Research Translation Network (CERTAIN) and informed by data from the Surgical Care and Outcomes ...