Plan and conclusion
By Mille Vissing, MD, Mie Pilegaard Bjarnesen, BCs. med. and Mia Wangsmo Steffenssen, MD
A short summary of the patient’s chief complaint and diagnoses/tentative diagnoses.
Details concerning the operation:
Assessment and proposed tentative treatment options. Will excision of a skin tumor, for example, cause a defect that can be ligated directly with a satisfactory result, or will there be a need for reconstruction with a flap or skin graft? If surgical treatment is chosen, state the planned surgical procedure, date, localization, laterality and whether the procedure requires general or local anesthesia. If the decision has been conferred with a specialist, note full name, and title.
Details concerning the patient:
Is the patient a candidate for the proposed surgery? Will surgery require optimizing the patient’s nutritional- or general health status or require discontinuing the use of drugs or certain medications?
Risk of excessive bleeding should always be considered, especially when dealing with patients receiving anticoagulant treatment. If the patient is taking blood thinning medicine consider the need for pausation, bridging or INR monitoring. The regulations from the Danish Society of Thrombosis and Haemostasis is used in Denmark (https://www.dsth.dk/bridging2018/index.html).
Assess the venous thromboembolism risk by calculating the Caprini score of the patient: https://www.mdcalc.com/caprini-score-venous-thromboembolism-2005
Document that oral and written information was given to the patient about their condition, planned investigations, therapies or procedures, and any related risks.
Prescriptions: List any prescriptions such as blood tests, EKG, or other special investigations needed. Pre-operative medications and changes made in the patient’s medication is prescribed as well.
Informed consent: Documentation that the patient is informed of and agrees to the plan of care and surgery.
Document the exact risks the patient is informed about