PROCEDURE: surgery performed.
SURGEONS: attending, residents, students who scrubbed.
FINDINGS: acutely inflamed gallbladder, 4-cm. diameter cyst, etc.
ANESTHESIA: general endotracheal (GETA), spinal, local, etc.
FLUIDS: amount and type (electrolytes, blood, etc. in cc or units).
ESTIMATED BLOOD LOSS: amount in cc.
DRAINS: type and location (T-tube in RUQ, etc.).
SPECIMENS: type sent to pathology (gallbladder and cystic duct, etc.).
CONDITION: stable, extubated, transferred to recovery room, etc.
Progress (SOAP) Note
Cardiology Progress Note and Consult
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