St. Joseph’s/Candler Health System

Dictation Guide

H&P must be Dictated W/I 24 hrs of admission
HISTORY & PHYSICAL / OP NOTE MUST BE DICTATED IMMEDIATELY AFTER SURGERY
Report of operation
MEDICAL HISTORY
Date of Admission
Chief Complaint
Present Illness
  1. Onset
  2. Duration
  3. Course
Past Medical History
Past Surgical History
Review of Systems
Allergies
Family History
Social History
Inventory of Body Systems
Psychosocial Needs
Assessment of:
-Emotional
-Behavioral
-Social / GENERAL PHYSICAL EXAM
Vital Signs
General Description
Skin & Mucous Membranes
HEENT
Neck
Chest & Lungs
(to include breasts)
Heart
Abdomen
Pelvis and/or Genitourinary
Rectal
Extremities, Joints & Spine
Neurological
Laboratory Data
Conclusions/Impression
Planned Course of Action / Date of Operation
Preoperative Diagnosis
Postoperative Diagnosis
Name of Operation
Surgeon
Assistants
Type of Anesthesia
Indication for Procedure
Description ofProcedure in Detail
Findings
Specimens Removed
Estimated Blood Loss
Complications
Prosthetic devices, grafts, tissues, transplant or devices implanted
Condition at Termination of Surgery
PROCEDURE NOTE MUST BE DICTATED IMMEDIATELY AFTER PROCEDURE
OUTPATIENT PROCEDURE NOTE

Date of Procedure

Name of Procedure
Indication(s) for Procedure
Premedication
Examination/Findings
Procedure Description
Specimens Removed
Estimated Blood Loss
Complications
Post-Procedure Diagnosis
Plan
CN MUST BE DICTATED IMMEDIATELY AFTER CONSULT
CONSULTATION NOTE / D/S MUST BE DICTATED
W/I 21 DAYS OF DISCHARGE
DISCHARGE SUMMARY /

REQUIRED IMMEDIATELY

HANDWRITTEN POST PROCEDURE REPORT
Date of Admission
Date of Consult
Attending Physician
Reason for Consult
History of Present Illness
Past Medical History
Past Surgical History
Allergies
Current Medications
Family History
Physical Examination
Laboratory Data
Impression
Recommendations / Date of Admission
Date of Discharge
Reason for Admission
Significant Findings
Procedures
Treatment
Condition at Discharge
(in relation to that on
Admission
Relevant Final Diagnoses
Conclusions from hospitalization
Discharge Instructions:
-Activity
-Medications
-Diet
-Follow up Care / Date of Procedure
Name of Physician/Assistant
Procedure
Description of each procedure finding
Post-Op Diagnosis
Specimen Removed
Estimated Blood Loss
Complications
Condition of patient