Documentation Templates

Thoracic discharge diet Author: Garrett Skinner Service: Thoracic Copy template

May resume regular diet as tolerated. Remain upright while eating. Encouraged to take small bites and chew thoroughly. Use over the counter stool softeners & laxatives as needed for constipation.

Thoracic GI discharge diet Author: Garrett Skinner Service: Thoracic Copy template

May continue full liquid diet as tolerated. Remain upright while eating. Encouraged to take small bites and swallow slowly. Your diet will be advanced if appropriate upon your first follow up visit to clinic. Encouraged to use stool softeners as needed while taking narcotic medication.

Thoracic discharge activity Author: Garrett Skinner Service: Thoracic Copy template

Day to day activity, no heavy lifting, pushing, pulling > 10lbs, no driving while taking opiate medications

Thoracic discharge hygiene Author: Garrett Skinner Service: Thoracic Copy template

OK to shower, no hot tubs, baths, pools, submerging incisions under water until completely healed. Monitor for redness, increased or changed drainage or swelling around incision sites. No lotions creams or oils over incision sites. Remove chest tube dressing prior to showering, replace with gauze and tape or bandaid if continues to drain fluid. Fluid may continue to drain for a couple of days post-operatively especially with coughing/sneezing or bearing down. Fluid may be orange, red, pink or yellow. If fluid looks milky or thick please call.

11R lymph node Author: Garrett Skinner Service: Thoracic Copy template

Dissection was carried up to the level of the lower border of the right bronchus intermedius. 11R lymph nodes were excised and sent for permanent pathology.

9 node Author: Garrett Skinner Service: Thoracic Copy template

Attention was turned to the inferior pulmonary ligament. This was released with electrocautery to the level of the inferior pulmonary vein. Level 9 lymph nodes were sampled and sent for permanent pathology.

Lateral decubitus with bean bag Author: Garrett Skinner Service: Thoracic Copy template

The patient was placed in the [left/right] lateral decubitus secured with straps, beanbag and all bony prominences padded. Bronchoscopy was again performed confirming appropriate location of the double lumen ET tube.

Intubation with double lumen Author: Garrett Skinner Service: Thoracic Copy template

General anesthesia was induced the patient was intubated with a double-lumen ET tube. Bronchoscopy confirmed appropriate position of the tube.

Thoracic MDC template Author: Garrett Skinner Service: Thoracic Copy template

New clinical problem: [] Case summary: [] Disease-specific elements: [] Other PMH: [] Other SH: [] Reason for presentation: []

Thoracic ROS Author: Garrett Skinner Service: Thoracic Copy template

She/He denies recent illness, fever, chills, SOB, cough, weight loss, hemoptysis or night sweats. She/He is no longer smoking.

Thoracic GI general plan Author: Garrett Skinner Service: Thoracic Copy template

Plan: dc NGT UGI this AM; results pending possible clear liquid diet with plan to transition to full liquid for discharge IV pain meds; transition to oral once able bowel regimen once able to take oral possible discharge home if tolerates diet and no concerns on UGI

Thoracic general plan Author: Garrett Skinner Service: Thoracic Copy template

Continue to encourage coughing and deep breathing, incentive spirometer 10x/hr Multimodal pain control with oxycodone, dilaudid, tylenol and lidocaine patches CT to -20cm suction Duonebs and mucomyst q4h for increased secretion clearance Metoprolol for afib ppx DVT ppx with LVX Continue home medications OOB as tolerated, PT/OT for strengthening/discharge CXR in AM or sooner if needed

Thoracic home atrium shower instructions Author: Garrett Skinner Service: Thoracic Copy template

Wipe down with water and wash cloth being careful to avoid chest tube site, can shower with chest tube dressing completely covered with transparent dressing, however, chest tube dressing needs to be changed after shower.

7 lymph node station Author: Garrett Skinner Service: Thoracic Copy template

The posterior pleural was opened dissection was opened and dissection carried into the subcarinal space and level 7 lymph nodes were excised.

Thoracic exam Author: Garrett Skinner Service: Thoracic Copy template

General: NAD Head and neck: normocephalic Respiratory: unlabored on [room air/nc/etc] Cardiovascular: WWP Abdomen: non-distended Extremities: non-traumatic Psych: normal affect Neuro: non-focal

Thoracic discharge instructions Author: Garrett Skinner Service: Thoracic Copy template

Return to ER/ATC with fever > 101, chills, worsening chest pain, shortness of breath, abdominal pain, nausea, vomiting, redness/warmth from incision sites, purulent drainage from incisions, increased swelling or pockets of air in chest/neck. Pain management: Use tylenol (acetaminophen) 650mg every 6 hours as needed for pain. You can alternate with Ibuprofen 600mg every 6 hours as needed for pain and use oxycodone (see prescription orders) for breakthrough pain.

10R lymph node station biopsy Author: Garrett Skinner Service: Thoracic Copy template

Attention was turned to the area just inferior to the azygous vein and the right mainstem bronchus and level 10R lymph nodes were excised.

4R and 2R lymph node station biopsy Author: Garrett Skinner Service: Thoracic Copy template

Next attention was turned superior to the azygous in the paratracheal space and level 4R lymph nodes were excised and further superiorly level 2R lymph nodes were excised.

VATS Wedge resection with CT marker Author: Garrett Skinner Service: Thoracic Copy template

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. A safety check was performed before induction of anesthetic and all were in agreement of patient and procedure and side. General anesthesia was induced the patient was intubated with a double-lumen ET tube. Bronchoscopy confirmed appropriate position of the tube and did not show any evidence of disease in the [] bronchi. The patient was placed in the [right/left] lateral decubitus secured with straps, [beanbag/anterior and posterior pads] and all bony prominences padded. Bronchoscopy was again performed confirming appropriate location of the double lumen ET tube. The [left/right] chest was prepped including the marker placed by the interventional radiologists, allowed appropriate time to dry and draped in normal sterile fashion. Timeout was done confirming patient, procedure, equipment, imaging, allergies and all were in agreement. The anesthesia team began single lung ventilation. The first incision was made along the mid axillary line approximately [number] rib space. This was carried down through the muscle layer and the pleural cavity was entered bluntly. A second port was placed along the anteriorly at the level of the [rib number] rib space under direct visulaization. Upon entering the pleural cavity it was noted that [findings]. CT guided marker string was visible in the [lobe]. The [lobe] at the location of the CT-guided marker was grasped and retracted and compression clamp was placed. Next the wedge resection was performed using sequential endogia staple loads. The specimen was divided from the remaining lung and the staple line and was noted to be hemostatic. The specimen was removed in a bag. The [nodule/marker/both nodule and marker] were palpated. Attention was turned to the inferior pulmonary ligament. This was released with electrocautery to the level of the inferior pulmonary vein. Level 9 lymph nodes were sampled and sent for permanent pathology. [other nodal station dictation] Posterior rib blocks were performed with Ropivacaine. Attention was turned to the port sites. Hemostasis was achieved with electrocautery. A [size] French chest tube was placed through the mid axillary line port and positioned superior to the lung to the apex of the thorax. The lung was inflated completely under direct visualization. The anesthesiologist did not note any air leak. The chest tube was connected to the atrium and to suction. A 2-0 Vicryl u-stitch was placed around the chest tube at the muscle layer. The chest tube was secured to the skin with 0 Ethibond. The anterior port was closed at the muscular layer with 2-0 Vicryl figure-of-eight stitch and at the deep dermal layer with buried interrupted 2-0 Vicryl. The skin was closed with running 4-0 Monocryl and Dermabond. Chest tube dressing was applied. All counts were noted to be correct. The patient was liberated from anesthesia uneventfully and transported the PACU in stable condition. Postoperative PACU chest x-ray with was ordered.