FOLLOW UP THT (POST-OP)

Date/Time: Assigned Doctor: dr. Floor/Room: Lt. /

PATIENT INFORMATION
Patient’s Name:

Sex: Medical Record: Date of Birth: Age (year): Date of Admission:

M / F

Chief Complain: Physical Examination:

Past Medical History (PMH): Risk Factors: Allergies:

Op Indication:
Pre-Op Diagnosis:
Post-Op Diagnosis:
Procedure: Post-operative day (POD#):

Others:
S–O–A–P
Past significant S-O-A-P: Date: / /
S:
O:
A:
P:

S O A P
Mual TTV:
Muntah - HR : _______________ x/mnt
- RR : _______________ x/mnt
Nyeri ____________________ - BP : _______/_______ mmHg
Demam - Temp : _____________ ͦC

Sekret/Pus/Darah
Otalgia
Epistaxis
Haemolacria (nangis darah)
Nyeri kepala
Pusing berputar
 FOLLOW UP THT (POST-OP)

Date/Time: Assigned Doctor: dr. Floor/Room: Lt. /

PATIENT INFORMATION
Patient’s Name:

Sex: Medical Record: Date of Birth: Age (year): Date of Admission:

M / F

Chief Complain: Physical Examination:

Past Medical History (PMH): Risk Factors: Allergies:

Op Indication:
Pre-Op Diagnosis:
Post-Op Diagnosis:
Procedure: Post-operative day (POD#):

Others:
S–O–A–P
Past significant S-O-A-P: Date:
S:
O:
A:
P:

S O A P
Mual TTV:
Muntah - HR : _______________ x/mnt
- RR : _______________ x/mnt
Nyeri ____________________ - BP : _______/_______ mmHg
Demam - Temp : _____________ ͦC

Sekret/Pus/Darah
Otalgia
Epistaxis
Haemolacria (nangis darah)
Nyeri kepala
Pusing berputar
Note urine output, JP drain output, any nausea or vomiting, and whether or not the patient is tolerating
the current diet (and note whatever diet that is - clear liquids, sips only, regular house diet, etc). Do a
regular physical exam, listening to heart, lungs, etc. Check the incision, and note if it is c/d/i
(clean/dry/intact). See if the patient's pain is reasonable for the size of his/her operation, or if it is out
of proportion. There will be other things to check for, depending on what operation was done, but this
should be enough to get you started.

To clarify: do not take the dressing down unless you have been told to. Just look to see if the dressing
is intact and not heavily stained with blood or other bodily fluids. Most surgeons say dressing down in
48 hrs, but we had one who insisted on POD #5.

1. vitals: one of the things you'll be pimped on for sure are the causes of post operative fever, and when they are most likely to happen. Something
like the "five Ws" or something...I'm not even sure if there's any evidence to support this little piece of surgical dogma, but you'll be asked it
that's for sure.

2. ins/outs. Ins being fluids, oral intake. Outs being drains, urine, feces, NG, vomitus etc.

3. Any symptoms that the patient is complaining of like NV, wound pain, chest pain, etc. Always ask if they're farting. So important. Surgeons
love to talk about things like ileus and obstructions. You'll get pimped on that heavy.

4. Regular physical exam: the legs(for DVT), the lungs, general fluid status and incision, essentially, with more attention given to anything else
that the symptomatology may warrant. They'll ask you to record and do the rest but I've never encountered anything else that changed
management by doing an entire exam(still do it though, if nothing but to appease your superiors). Poking on the abdomen after abdo surgery is
a very mean thing to do, in my opinion.

5. Your plan of action given all of the above. Make sure to remember adequate analgesia and antinausea, and remember to try to get the
patient up and around sooner rather than later. The last thing you want is someone to be newly bedridden and deconditioned. Also, investigate
any concerning findings.

Now, that's all I can come up with for now. I hope it helps.

SAMPLE NOTES
Pre-Ops Note

Date
Time

Pre-Op Diagnosis:
Planned Procedure and Scheduled Time:
Indication:
Labs/studies:

---/---/---{ }---{ U/A LFT's

Official CXR reading: (on chart)

Official EKG reading: (on chart)
Type and Cross/Screen for __ units in blood bank
NPO after MN
IVF ordered after MN
 Antibiotics ordered on call to OR:
Anesthesia evaluation (on chart)
Operative Consent (on chart)

 If any of the above are missing or incomplete, call an intern!

 All abnormalities and/or omissions must be addressed!

Operative Note

Date
Time

Pre-Op Diagnosis: gallstone pancreatitis

Post-Op Diagnosis: same
Procedure: Laparoscopic cholecystectomy with Intraoperative cholangiogram
Surgeon: Lin
Assistants: Resident, MS
Anesthesia: GETA (General Endotracheal Anesthesia)
EBL: minimal
UOP (urine output): unmonitored (no foley) or amount
IVF: 2000 cc crystalloid
Findings: Intraabdominal adhesions, distended GB, +GS, cholangiogram: mildly dilated CBD, no filling defects, normal
intrahepatic radicles, uninterrupted flow into duodenum
Specimens: GB to pathology
Drains: None
Complications: None
Disposition: To Recovery Room, extubated, in stable condition

Surgery MS3 Progressive Note

Date
Time
Meds

POD#__ after ______________________________ Abx day #___

24hr events/subjective complaints

(Include presence or absence of nausea, vomiting, flatus, BM, ambulation, pain, chest pain, SOB, and other PERTINENT info.)

Vitals: Tmax, Tcurrent BP(range) HR(range) RR(range) Pox (if available)

I/O: Total In/Total Out
8hr shifts - Ins broken down into IVF, PO, NGT, feeding tube, etc.
8hr shifts - Outs broken down into NGT, U/O, stool, emesis, drains, etc.
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
Labs (do not present orally if previously presented on rounds)
A/P: __ year old man/woman POD#___ after ______________________ progressing well
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

Surgery MS3 ICU Progressive Note

Date
Time

Significant 24hr events/road trips, subjective complaints (Ask the nurses!)

Meds

Neuro: PE, GCS, sedative drips, pain control CV: PE/vasc exam (where appropriate)
HR (range) BP (range) CVP (range)
Cardiac parameters (if PA cath in place)
CO CVP
CI PCWP
PAS/PAD SVR
SV

Resp: PE
RR (range) Pox ___% on RA/___%FIO2
Vent settings: mode, rate, TV, FIO2, PS, PEEP
ABG: pH/pCO2/pO2/TCO2/BE or BD/sat on latest vent settings

GI: PE incl wound, diet/tube feeds, drains/NGT output, LFT's

Renal/FEN: 24hr I/O's including breakdown into component parts

IVF rate
UOP/hr (in cc/kg/hr)
Labs: ---/---/---{ Ca, Mg, PO4

Heme/ID: Tmax, Tcurrent Abx day#___

}---{ PT/PTT Cx results:
Endocrine: Accuchecks, Insulin dosing, TFT's, steroids

A/P: ICU Day#___, POD#___after____________________

Neuro:
CV:
Resp:
GI:
Renal/FEN:
Heme/ID:
Endocrine: