History and Physical Advice Tips Secrets

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Post Operative Note

PROCEDURE: surgery performed.

S: patient comments or complaints, nursing comments, CHECK consciousness (alert, oriented, drowsy), pain control, passed gas, urine? Bowel movements, chest pain, shortness of breath, etc.

O: VITALS: blood pressure, pulse, respirations, temp, O2 sat, etc.

INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains, etc.

EXAM: physical findings (incision/dressing, neurovascular status, etc.).

LABS: results of any since surgery.

A: assessment based on above data.

P: medication changes, lab tests, procedures, consults, discharge, etc.

 

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Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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