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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]
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A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.
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.
Laparoscopic surgery, also called minimally invasive procedure, bandaid surgery, or keyhole surgery, is a modern surgical technique. There are a number of advantages to the patient with laparoscopic surgery versus an exploratory laparotomy. These include reduced pain due to smaller incisions, reduced hemorrhaging, and shorter recovery time.
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