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Post-Operative Note:

Date\Time:

ID: Name, Age, Sex, Post-Op Day #, after what kind of surgery?, Abx day #___,

 

Subjective:

24hr events/subjective complaints: Including presence or absence of nausea, vomiting, flatus, BM, ambulation, pain, chest pain, SOB, and other PERTINENT info.

Objective:

Vitals: Tmax, Tcurrent, BP (range over 24 hrs), HR(range over 24 hrs) RR (range over 24 hrs), Blood sugars (AM, Afternoon, PM)

 

Total In/Total Out:
        Intake in total over past 24 hrs: ____ cc, of that ______ cc from IV, ______ cc Nasogastric tube, ________ cc PO etc...
        Output (Just urine) in total over past 24 hrs: ____ cc total, ____CC/kg/hr

 

PE: Lungs – CTA bil
       Heart – RRR, no M/R/G
       Abdomen – soft, ND/NT, normoactive BS
       Wound – well-approximated, no erythema or d/c
       Stoma – pink, patent, productive of stool
       Ext – no edema
 

New Labs:

 

Assessment: __ year old man/woman POD#___ after ______________________ progressing well

Plan: (Systems based):

Neuro: Pain control adequate, continue PCA, OOB, ambulate today
CV: Mild tachycardia, will bolus with 500cc isotonic crystalloid and reevaluate
Resp: No issues, continue spirometry
GI: Await return of bowel function, continue NPO, NGT
GU: U/O marginal, continue to monitor closely after volume load, Replete electrolytes
Heme: HCT 27 and stable, continue SQ Heparin
ID: Perioperative abx D/C'd, afebrile, check WBC today
Endocrine: Continue ISS, BS well controlled 

Disposition: Whats keeping them from going home?