1.

Progress Note
a. Subjective
Patient is a ________ year old ________ POD_ s/p ________
Overnight patient was AF, VSS, NAE (severe hypotensive events requiring intervention)
b. Objective
VS – HR ____ BP ____, Tmax ____, Tcurrent ____, RR____, SaO2 ____ on ____
I/O – ____ in (____ of NS, ____ of PO) and ____ out (emesis/drains/stool/urine)
Neuro – GCS ____, motor ____/5, sensation to light touch intact all 4 extremities
HEENT – NCAT, EOMI, intubated/oxygenation device
Resp – CTAB
CV – RRR, no MRG
Abd – nondistended, (+) BS all 4 quadrants, (+) ttp ____, incision CDI, staples in place, w/o erythema,
(drains)
EXT – warm, 2+ DP/PT/radial pulses
Lines – PIV, Foley, JP drains
c. A/P
Mr/Mrs ________ is a ________ year old ________ POD ________ s/p ________ by Dr. ________ who
is doing well
Diet plan or NPO until ________
Pain controlled with ________ progress to ________ as tolerated
Volume status – IVF, UOP, Vitals
Any specific problems (lytes, pulmonary – extubate, fever)
GI, DVT PPX
Discharge plan – best guess as to when and what needs to be done to get there
d. A/P
Mr/Mrs ________ is a ________ year old ________ POD ________ s/p ________ by Dr. ________ who
is doing well
Neuro: Pain (well/adequately) controlled, continue ________ (PCA/IV/PO)
OOB, ambulate ________ (today/tomorrow)
CV: (No/Mild/Mod) tachycardia, will (continue IVF/bolus with 500cc isotonic crystalloid and reevaluate)
Resp: No issues, continue spirometry (extubate today/continue NC)
GI: (Await return of bowel function, continue NPO, NGT) vs (Passing flatus/stool, progress diet)
GU: UOP ________ (marginal/adequate/good), continue to monitor (closely) after volume load
Replete electrolytes
Heme: H&H ________ (stable/improving/declining), continue SQ Heparin
ID: Perioperative abx (D/C'd/continued), (afebrile/febrile), check WBC today
Endocrine: Continue ISS, BS well controlled
e. Stated plan
i. Mr/Mrs ________ is a ________ year old ________ POD ________ s/p ________ by Dr.
________ who is doing well
ii. Pain control
iii. HR and IVF decision
iv. Respiratory
v. GI/FEN
f. A/P: 33 yo female, POD # 2, s/p appendectomy. Patient doing well
i. Low grade fever – likely secondary to atelectasis
1. Continue incentive spirometry
2. Continue Flagyl antibiotics
3. T/C blood cultures if continued fever
 4. Encourage ambulation
ii. Pain is improving
1. T/C switching PCA to oral analgesic
iii. Diet – tolerating clear liquids
1. Advance to house/regular diet
iv. Good urine output
1. D/C Foley
v. Prophylaxis
1. Continue incentive spirometry
2. Continue SCDs
vi. Dispo: Pending PO pain mgmt. and inc oral intake
2. New Patient Consult Note
a. This note should reflect pertinent historical and objective data relevant to the current surgical problem
at hand with a chronological, problem focused approach
b. Attention should be paid to factors supporting the diagnosis and ruling out others in the differential,
indications and contraindications for surgical intervention, and factors influencing reliability of overall
clinical picture
c. Other pertinent information includes factors relevant to anesthesia and perioperative risk. For
example: last meal, relevant comorbidities—CV, pulm, systemic anticoagulation, hx hypercoaguability,
rx to meds etc--and level of hydration/nutritional state
3. Op Note
Date/Time
Name of Surgeon:
Name of Assistant:
Pre-Operative Diagnosis:
Post-Operative Diagnosis:
Procedure Performed:
Findings:
EBL (estimated blood loss):
Specimens:
Drain:
Complications
4. Post-Op Admission Orders – ADC VANDALISM PAAC
a. Date Time Post-OP Orders MSIII ________ Surgery
Admit: ________
Diagnosis: ________ s/p ________
Condition: (Stable/Unstable)
Vitals: ________ (q shift)
Allergies: ________
Nursing orders: Strict I/Os, SCDs, Foley catheter to gravity, Incentive spirometry
Diet: NPO
Activity: as tolerated
Labs: ________ (CBC, BMP & when)
IV fluids: D5 ½ NS + 20 KCL at rate of 100cc/hr
Studies: CXR
Meds: Abx: Cefotaxime 1g IV q8hrs for 24 hours 10
Prophylaxis: Heparin 5000 units SC
Analgesic: PCA (patient controlled analgesic) pump
Any pre-op medications the patient has been on and PRN meds
 Call house officer if HR > 100 or < 60, BP > 180/100 or < 90/60, Temp > 39.5
5. Post Operative Note (***at least 6 hours after surgery***)
(Date) (Time) MSIII ________ Surgery
Status: s/p ________, patient having ____discomfort
Neuro: ________ (AAOx3/)
VS: ________ (stable/afebrile)
I/O: ____ ml of ____/ ____ of (emesis/stool/drains/urine)
UO: 500cc x 6 hours
Labs: ____ (CBC, BMP) in ____ (6 hours, in the am)
Physical Exam:
CV: ____, ____ , ____ (RRR, (+) S1/S2, (-) m/r/g)
Lungs: ____ (CTA B/L)
Abd: Soft, ____ tenderness, (+/-) BS, dressing ____ (C/D/I)
A/P: ____ yo fe/male s/p ________ POD #0 in ____ (stable) condition
IV hydration
Pain management with PCA ____
Abx - (dose) (drug), (route), (freq), (duration) (1g cefotaxime IV q8hrs for 24 hours)
DVT prophylaxis: SCDs, heparin 5000 units sc
a. Example
6/2/16 1800 Post-OP Note MSIII Green Surgery
Status: s/p appendectomy, patient having mild discomfort
Neuro: AAOx3
VS: stable/afebrile
I/O: 1000ml LR
UO: 500cc x 6 hours
Labs: CBC, BMP in am
Physical Exam:
CV: RRR, (+) S1/S2, (-) m/r/g
Lungs: CTA B/L
Abd: Soft, RLQ tenderness, (-) bowel sounds, dressing C/D/I
A/P: 33 yo female s/p appendectomy POD #0 in stable condition
IV hydration
Pain management with PCA
1g cefotaxime IV q8hrs for 24 hours
DVT prophylaxis: SCDs, heparin 5000 units sc
6. Handoff Note
a. SBAR
Situation - Pt s/p ________ at ________
Background – (Healthy/Moderately healthy) patient, (un/complicated) procedure, additional
info
Assessment – (diagnosis) post (procedure),
Recommendation – post-op check tonight, ________ consulted, (procedures planned & when),
otherwise (________)
b. Sample SBAR note
S: Pt s/p lap chole with cholangiogram 1600
B: Healthy patient, uncomplicated procedure, unable to clear CBD stone on seen cholangiogram
A: Choledocholithiasis post lap chole, incidental, non obstructing
R: Post op check tonight, GI already consulted, ERCP tomorrow, otherwise nothing to do