The document provides guidelines for preoperative evaluation, admission notes, operative notes, and postoperative care of patients undergoing maxillofacial surgery. It discusses the purpose and key contents of admission notes, preoperative notes, informed consent processes, surgical site marking, brief operative notes, full operative reports, immediate postoperative notes, progress notes, postoperative orders, and discharge summaries. The guidelines aim to ensure thorough documentation and communication between healthcare providers regarding patient care.

1. Copy right 2021
Copy Right 2023
Preoperative Evaluation and Investigations for
Maxillofacial Surgery

2. BDS,MSc,MFDS RCS Ed, MOMS RCPS Glasd,
FFD RCSI,FDS RCPS GLasg
Senior Consultant OMFS
Head of OMFS Alamin Hospital
IMAXFAX center
Mr.Islam Kassem

3. • There is no conflict of interest in this lecture
• I have no monetary benefit from this
lecture .
• No implied sponsorship by any company to
the speaker
• all photographed patients were treated by
the speaker and consented for photographing
and public publishing

4. Our team

5. Admission Note
Purpose
An admission note is that part of a medical record that documents the patient’s status,
reason for admission for inpatient care to the hospital or other facility, and the initial
patient care instructions. Its purpose is to provide a concise and accurate assessment of
requirements of the patient to other health care providers who will be attending to the
patient. According to the Joint Commission, this must be completed and documented
within 24 hours following admission of the patient, but prior to surgery or a procedure
requiring anesthesia services (including moderate sedation).

6. Content
• Chief complaint (CC)
• History of present illness (HPI)
• Review of systems (ROS)
• Past medical history (PMH)
• Past surgical history (PSH)
• Allergies
• Medications
• Physical examination (PE)
• Assessment and plan
•

7. There are 14 systems recognized as follows:
• General
• Head, eyes, ears, nose, and throat (HEENT) as well as sinuses, mouth, and neck
• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Urinary system
• Genital system
• Vascular system
• Musculoskeletal system
• Nervous system
• Psychiatric
• Hematologic/lymphatic system
• Endocrine system
• Allergic/immunologic system

8. Admission Orders
Purpose
The purpose of the admission orders is to establish a set of clear and concise instructions
that will allow the nursing and auxiliary sta
ff
to manage the admitted patient according to
the requests of the admitting doctor. These are completed prior to admission to the hospital
through a standard set of instructions (ie, orders) that are to be carried out by the nursing
sta
ff
to ensure optimal care for the admitted patient.

9. Content
Diagnosis: The admission diagnosis according to the information that is available at the time (eg, maxillofacial trauma).
Condition of patient: Condition of the patient at the time of admission (eg, stable condition).
Vital signs: The interval at which the requisite vital signs, such as heart rate and blood pressure, are to be taken and recorded by the nursing sta
ff
(eg, record vital signs every [q] shift).
Activity: List the level of activity that you would like the patient to tolerate. Usually related to the type of injury, illness, or procedure that the patient has sustained or undergone (eg, as tolerated, out of bed to chair, encourage
ambulation).
Allergies: List any pertinent known allergies and, if available, the reaction that the patient has to that allergy (eg, penicillin w/ rash or no known drug allergies [NKDA]).
Nursing care: List the speci
fi
c orders that you require the nursing sta
ff
to perform, any consults requested, and when the admitting surgeon or service should be contacted in the care of the admitted patient (eg, nothing by mouth
after midnight [NPO MN], void bladder on call to operating room [OR]).
Diet: The type and route of nourishment of the admitted patient (eg, liquid PO diet).
Intravenous (IV)
fl
uids: The speci
fi
c type and amount of IV
fl
uid that the patient is to receive while in the hospital (eg, run dextrose 5% in half normal saline [D5 1/2 NS]
with potassium chloride [KCl] 20 mEq/L at 125 mL/h after MN).
Medications: Speci
fi
c name, route, dosage and interval of both hospital medications and home medications that patient may be taking (eg, 2 mg morphine IV q 4 hours as
needed [PRN] for pain).
Laboratory tests: List the speci
fi
c type of laboratory tests to be done on the patient

10. Preoperative Note
Purpose
The purpose of preoperative orders is to con
fi
rm that the patient is ready for surgery. This
includes con
fi
rmation that the necessary laboratory tests, radiographs, consultations, and
informed consents will be or are completed and assurance of their availability before
surgery.

11. Preoperative diagnosis
1. Right mandibular body fracture
2. Left mandibular subcondylar process fracture
3. Comminuted left zygomaticomaxillary complex fracture
Planned procedure and scheduled time: Open reduction and internal
fi
xation of fractures in operating room at 9 am tomorrow.
Indication: Facial bone and mandible fractures and malocclusion.
Labs/studies:
Na Cl BUN K HCO3 Cr Gluc WBC Hb Hct Plt
O
ffi
cial CXR and CT readings: Completed, reviewed, and on chart.
O
ffi
cial ECG reading: Completed, reviewed, and on chart. Type and cross-screen for 2 units in blood bank
NPO after MN
IV
fl
uids ordered after MN
Antibiotics ordered on call to OR: 3 g Unasyn (P
fi
zer) IV.
Anesthesia evaluation: Completed and on chart.
Operative consent: Signed, witnessed, and on chart.

12. https://www.elogbook.org/

13. Content
In general, the preoperative note should include at least the following information:
•Proposed surgical procedure
•NPO status
•Operative informed consent signed by the patient, surgeon, and witness, and
present in chart
•Laboratory test results

14. Preoperative Protocol
Informed consent
According to the World Health Organization, the American College of Surgeons, and the Joint Commission, it is critically important that the surgeon receive informed consent from the patient,
parent, or legal guardian before performing any procedure. Informed consent pertains to providing a full explanation in clearly understandable language of what you are proposing, your reasons
for wishing to undertake the procedure, and what you hope to
fi
nd or accomplish. Avoid the use of medical jargon. Be attentive to legal, religious, cultural, linguistic, and family norms and
di
ff
erences.
The informed consent process is completed in the following way:
Describe the planned procedure to the patient in understandable lay terms. Draw pictures and use an interpreter, if necessary.
Describe the risks associated with the procedure as well as those with any anesthesia.
Discuss any alternative methods of treatment.
Allow the patient and any family members to think about what you have said.
Ask the patient if they have any questions or concerns and address them.
Con
fi
rm that the patient has understood the plan.
Obtain written and verbal permission to proceed.
It may be necessary to consult with a family member or legal guardian/power of attorney who may not be present; allow for this if the patient’s condition permits. If a person is too ill to give
consent (eg, unconscious) and his or her condition will not allow further delay (eg, life-threatening airway obstruction from Ludwig angina), you should proceed without formal consent, acting in
the best interest of the patient. Record your reasoning and plan.

15. •Surgical Site Marking (Universal Protocol)
Purpose
The purpose of the Universal Protocol is to prevent the
occurrence of wrong person, wrong procedure, and/or
wrong site surgery in either hospital or outpatient settings.

16. The Universal Protocol consists of three stages:
1. Preoperative veri
fi
cation of the correct patient. Veri
fi
cation with at least two ideni
fi
ers (patient name, medical record number, and/or date of birth) ensures correct patient identi
fi
cation. Missing information and/or discrepancies must be addressed
before the start of the procedure, such as the history and physical examination
fi
ndngs and signed consent with the correct procedure veri
fi
ed in the medical record.
2. Marking the correct operative site. The Joint Commission as a part of its Universal Protocol mandates that the correct surgical site must be marked when there is more than one possible location for the procedure and when performing the procedure in a
di
ff
erent location could harm the patient (eg, right temporomandibular joint versus left temporomandibular joint). This is generally completed by the attending surgeon with the surgical site marked with his or her initials and “YES,” personally con
fi
rming the
surgical site is correct. The mark must be visible after the patient has been prepped and draped. Further, the Joint Commission guidelines purport: nnThe site does not need to be marked for bilateral structures (eg, bilateral temporomandibular joints).
The site is marked before the procedure is performed, ideally in the preoperative suite. If possible, involve the patient in the site-marking process.
The site should be marked by a licensed independent practitioner who is ultimately
accountable for the procedure and will be present when the procedure is performed. in limited circumstances, site marking may be delegated to a resident, physician assistant (PA), or advanced practice registered nurse (APRN). However, the licensed
independent practitioner is ultimately accountable for the procedure even when delegating site marking.The mark should be unambiguous and used consistently throughout the organization.
The mark must be made at or near the procedure site.
Adhesive markers are not the sole means of marking the site.
For patients who refuse site marking, or when it is technically or anatomically impossible or impractical to mark the site, it is recommended to use your organization’s written, alternative process to ensure that the correct site is operated on. However, some
anatomical structures such as teeth do not generally have to be marked.
3. Final veri
fi
cation/“Time out.” A deliberate pause in all activity is performed by a dedicated individual immediately before starting the procedure. Complete attention is given to the individual conducting the time out, and the following details are con
fi
rmed:
Patient name
Date of birth
Correct procedure site veri
fi
ed by the consent form
The correct site and side have been marked
Surgeon’s name
Procedure to be performed
All perioperative medications (antibiotics, etc) have been given Patient is properly positionedCorrect devices and any special equipment are available
4.

17. Brief Operative Note
Purpose
The brief operative note is created immediately after the surgery or procedure is complete and usually before the patient
leaves the operating room. This note highlights the important details of the completed procedure so the nursing sta
ff
at
the patient’s next level of care may be informed of what has occurred. The Joint Commission requires that the brief
operative note include the exact time it is written because it is very important to con
fi
rm that the note was recorded prior
to moving the patient to the next level of care.

18. Date/time: 09/08/2023, 10:02
Preoperative diagnosis: Mandible and facial bone fractures.
Postoperative diagnosis: Same.
Procedure: ORIF mandible and facial bone fractures.
Anesthesia type: GNETA.
Surgeon: Dr Islam .
Assistant(s): Dr Bassel .
EBL: 20 mL.
IV
fl
uids: 1200 mL lactated Ringer (B Braun).
Urine output: Approx 40 mL.
Findings: Displaced mandibular and facial bone fractures.
Pathology: None.
Disposition: Patient tolerated the procedure well and was taken to PACU without complications.
•

19. Content
The brief operative note is a condensed and concise version of the more detailed operative note. It should contain the following information:
•Date/time: MM/DD/YYYY: 00:00
• Preoperative diagnosis: Reason for surgery
• Postoperative diagnosis: Diagnosis based on
fi
ndings at surgery • Procedure: What procedure(s) were performed
• Anesthesia (type): General, spinal, epidural, etc
• Surgeon: Name of attending physician
• Assistant(s): Resident, medical student, dental student, PA, etc
• Estimated blood loss (EBL): Estimated amount of blood lost during the procedure
• IV
fl
uids: Type and amount of IV
fl
uid administered
• Urine output: Amount of urine produced through the catheter during the operation
• Findings: Detailed description of what was found at surgery; describe sizes, location,
etc
• Pathology: Specimens that were sent to pathology for evaluation
• Disposition: Where patient is going from the operating room
•

20. •Operative Report
•Purpose
The operative note or report details the procedure completed on the patient as dictated by the operating
surgeon of record or designated associates (ie, resident or PA). If the individual dictating is di
ff
erent from
the surgeon of record, the report will include his or her name as well. Operative reports are created after
every surgical procedure for the purposes of both documentation and billing. The Centers for Medicare and
Medicaid Services require that the operative report be completed immediately after surgery, while the Joint
Commission will allow a hospital to de
fi
ne what this time period would be if there has been a brief operative
note already dictated.

21. •Content
•
• Preoperative diagnosis: Working diagnosis of perceived problem
• Postoperative diagnosis: Final diagnosis after the surgery is completed, adding any additional information that was not available prior to surgery
• Procedure(s): Detailed list of surgical procedures performed by the operating team
• Statement of medical necessity: Medical reason for the patient to have the procedure performed
• Surgical service: Service performing the surgery
• Attending surgeon: Name of the surgeon of record
• Assistant surgeon(s): Those who were scrubbed and participated in the surgery
• Anesthetic administered: The type of anesthetic used and method of administration (eg, general nasoendotracheal anesthesia, monitored anesthesia care)
• Operative report: Detailed description of the operative procedure as told by the individual who performed the procedure or a designated associate
• Specimen(s): Any tissue,
fl
uid, or material removed from the patient during surgery intended for examination
• Drains: Type and location of any device intended for
fl
uid drainage
• IV
fl
uids administered: Amount and type
• EBL: Estimation of blood lost during the surgery usually based on conference between members of the operating room team
• Urine output: Obtainable when a Foley catheter has been placed
• Complications: Detailed description of any perceived intraoperative complications
• Disposition: The condition of the patient at the end of the surgery and where patient is being sent

22. Immediate Postoperative Note
Purpose
The purpose of the immediate postoperative note is to assess the recovery status of the
patient in the immediate postoperative period (ie, the
fi
rst few hours following the
procedure) and once out of the postoperative care unit or postanesthesia care unit
(PACU) and on the nursing
fl
oor. This will include the
fi
ndings from a physical
examination to ensure early detection of any potential post anesthesia or postoperative
complications such as pulmonary embolism, deep vein thrombosis, atelectasis, and so
forth.

23. Content
The postoperative note should be more detailed than a regular progress note and should provide information
about the patient’s immediate postoperative recovery. This should include the
fi
ndings on an examination of
the patient’s lungs, heart, abdomen, extremities, and neurologic status. The note should list both the hospital
day (HD) number and the postoperative day (POD) number.

24. Progress Note (SOAP Note)
Purpose
This note indicates the patient’s current status and
further plans. The SOAP note easily lends itself to
an organized and recognizable standard format
that allows for a succinct and informative narrative
of the patient’s daily hospital course.

25. Content
• Subjective: Describe how the patient feels (eg, current symptoms).
• Objective: This includes
fi
ndings on physical examination, vital signs, laboratory results, etc.
• Assessment: Based on the above information, the practitioner’s opinion about the patient’s current status is presented.
• Plan: What is planned for the patient, such as change in medication, additional tests, discharge, etc. It may also include
directives, which are written in a speci
fi
c location as orders.

26. Postoperative Orders
The purpose of postoperative orders is to con
fi
rm that the
fi
ndings
and e
ff
ects of surgery are properly considered. As all previous
standing orders are automatically canceled when the patient goes
to the operating room, these orders must be recreated, if
indicated, and also include any new orders that need to be added.

27. Content
Postoperative orders are written similar to the admission
orders using the same mnemonic ADCVAANDIML, but they
are updated based on the procedure that was completed on
the patient.

28. Discharge Summary
Purpose
The purpose of a discharge summary is to succinctly
summarize the events of the hospitalization for the patient’s
primary care physician and other subspecialists. It is not a
day-to-day documentation of the patient’s hospital course.

29. Content
Date of admission/transfer: MM/DD/YYYY
Date of discharge/transfer: MM/DD/YYYY
Admitting diagnosis: Working diagnosis at the time of admission. This can be a presenting symptom (eg, oral bleeding).
Discharge diagnosis: The diagnosis at time of discharge cannot be a symptom or sign.
Secondary diagnoses: Include all active medical problems regardless of whether they were diagnosed during this admission.
Procedures: List all procedures with the date of occurrence and key
fi
ndings, when applicable.
Consultations: List names and specialties of all consultants who saw the patient while an inpatient (eg Dr Smith, infectious disease).
History of present illness: A brief summary (one to two sentences) of how the patient initially presented. May be followed by the phrase “see full H&P (history and physical) for details.”
Hospital course: Detailed account of the hospital stay, highlighting signi
fi
cant interventions and/or episodes such as any complications or improvements based on speci
fi
c treatments. This information should be thorough but not exhaustive in detail, such as day-by-day speci
fi
cs of activity and medication
regimens.
Condition of patient: Provide a brief functional and cognitive assessment.
Disposition: Where the patient is going following discharge from the hospital (eg, skilled nursing center, home with daughter).
Discharge medications: List all the patient home medications prescribed, including doses, route of administration, frequency, and date of last dose, when applicable.
Discharge instructions: Speci
fi
c details of activity level, diet, wound care, or other issues the patient’s doctor needs to know. This is di
ff
erent from the discharge instructions you give to patients, which include symptoms and signs to report or seek care for (eg, “call Dr X if temperature greater than 100” or “go to ER
if chest pain returns”) and must be in language they understand. They also should include a 24/7
callback number.
Pending studies: List all studies that are outstanding and to whom the results will be sent.
Recommendations: Include any necessary consults or studies that should be done.
Follow-up: Name of doctor, specialty, and appointment location and time. If the patient is to schedule the appointment, make sure you include the time frame in which the patient should schedule the appointment (eg, patient to arrange appointment to be seen within 2 weeks).
•

30. • Thank you
• ikassem@dr.com
• 00201559900333