S:
– Pt is a __yo M/F with (diagnosis that required operation) now s/p
(operation).
– Intraoperative complications, issues with anesthesia, intubation, significant
events since OR
– Current complaints from patient
O:
– Operative I/Os: IVF, blood products, EBL, UOP
– VS, Physical Exam, don’t forget about new tubes, lines, drains
– Labs, imaging since coming out of the OR (don’t care about intra-op labs)
A: Summarize patient as above
P: Easy things to include:
- Wean oxygen, IS/pulm toilet, encourage ambulation, diet, pain control, wound care,
when to resume important home meds (look at the patient’s post-op orders).
What to include in post-op note