Date Time

Post-operative Day Number: Problem List: Antibiotic day number and hyperalimentation day number if applicable. List each surgical problem separately (eg, status-post appendectomy, hypokalemia). Subjective: Describe how the patient feels in the patient's own words, and give observations about the patient. Indicate any new patient complaints, note the adequacy of pain relief, and passing of flatus or bowel movements. Type of food the patient is tolerating (eg, nothing, clear liquids, regular diet). Objective:

Vital Signs: Maximum temperature (Tmax) over the past 24 hours. Current temperature, vital signs.

Intake and Output: Volume of oral and intravenous fluids, volume of urine, stools, drains, and nasogastric output. Physical Exam: General appearance: Alert, ambulating. Heart: Regular rate and rhythm, no murmurs. Chest: Clear to auscultation. Abdomen: Bowel sounds present, soft, nontender.

Wound Condition: Comment on the wound condition (eg, clean and dry, good granulation, serosanguinous drainage). Condition of dressings, purulent drainage, granulation tissue, erythema; condition of sutures, dehiscence. Amount and color of drainage Lab results: White count, hematocrit, and electrolytes, chest x-ray Assessment and Plan: Evaluate each numbered problem separately. Note the patient's general condition (eg, improving), pertinent developments, and plans (eg, advance diet to regular, chest x-ray). For each numbered problem, discuss any additional orders and plans for discharge or transfer.

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