Orthopedic Inpatient Protocols
A Guide to Orthopedic Inpatient Rounding
by
Miriam Wiggins
Copyright 2011 Miriam Wiggins,
All rights reserved.
Published in eBook format by eBookIt.com
ISBN-13: 978-1-4566-0043-3
No part of this book may be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems, without permission in writing from the author. The only exception is by a reviewer, who may quote short excerpts in a review.
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.)
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