Postoperative Check

A postoperative check should be completed on the evening after surgery. This check is similar to a daily progress note.

Example Postoperative Check

Date/time:

Postoperative Check

Subjective: Note any patient complaints, and note the adequacy of pain relief.

Objective:

General appearance: Vitals: Maximum temperature in the last 24 hours (Tmax), current temperature, pulse, respiratory rate, blood pressure. Urine Output: If urine output is less than 30 cc per hour, more fluids should be infused if the patient is hypovolemic. Physical Exam: Chest and lungs: Abdomen:

Wound Examination: The wound should be examined for excessive drainage or bleeding, skin necrosis, condition of drains. Drainage Volume: Note the volume and characteristics of drainage from Jackson-Pratt drain or other drains.

Labs: Post-operative hematocrit value and other labs.

Assessment and Plan: Assess the patient's overall condition and status of wound. Comment on abnormal labs, and discuss treatment and discharge plans.

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