Post-Operative Note (letter style)

OVERALL_INSTRUCTIONS

Chief Complaint

Post-Operative Note

Template

Post-Operative Note Date/Time: Patient Identification: [Enter patient name, medical record number, age, sex] Surgeon/Assistants: [Enter attending surgeon and any assistants] Preoperative Diagnosis: [Enter preoperative diagnosis] Postoperative Diagnosis: [Enter postoperative diagnosis] Procedure Performed: [Enter name and description of procedure(s) performed] Indications: [Briefly state why surgery was indicated] Anesthesia: [Type of anesthesia and relevant anesthetic details] Estimated Blood Loss: [Enter EBL in mL] Fluids and Blood Products: [Detail intraoperative IV fluids, crystalloids, colloids, blood products] Specimens Removed: (hyphenated list) - [Specimen 1: description] - [Specimen 2: description] Drains/Tubes: (hyphenated list) - [Type/location of drain or tube; output if applicable] - [Next planned change or removal date] Dressings:[Describe current dressing(s) over incision site(s)] Postoperative Vital Signs: (hyphenated list) - Heart rate: [#] bpm - Blood pressure: [#]/[#] mmHg - Respiratory rate: [#] /min - Temperature: [#] °C/°F - O₂ saturation: [%] on [room air or device] Intake and Output: (hyphenated list) - Intake: [type and volume] - Output: [type and volume] Plan: (hyphenated list) - Pain management: [e.g., Continue IV opioids, transition to PO as tolerated] - Antibiotics: [e.g., Continue cefazolin IV until post-op day 2] - Diet: [e.g., NPO → clear liquids → regular as tolerated] - Activity: [e.g., Ambulate with assistance 3×/day] - IV fluids: [e.g., D5½NS at 75 mL/hr] - Labs/Imaging: [e.g., CBC and BMP morning of post-op day 1] - Wound care: [e.g., Change dressing daily; monitor for signs of infection] - Discharge planning: [e.g., Anticipated post-op day 3; physical therapy eval] Disposition: - [Enter current postoperative condition, level of care (e.g., ICU vs. floor), and follow-up plan]