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.
Progress (SOAP) Note
Cardiology Progress Note and Consult
Learn how to do an H&P correctly!
Look like a superstar physician!
Don't make rookie mistakes!
Outshine your cohorts!
Be able to bill better!
Make a case for a higher level of care!
The money is in the assessment and plan!