POST-OP NOTE

Patient: [Name, age, record number]
Location: [Ward and bed]
Date and time seen: [Date and time]
Operation: [Procedure, date, and surgeon]
Postoperative day: [Day number, counting the day of surgery as day 0]
Operative details to watch: [Findings, anastomosis or stoma, drains, estimated blood loss, and anything the operative note flags]
Author: [Name, role, surgical team]

SUBJECTIVE
Overnight events: [Calls to the team, rapid responses, new orders, or none]
Pain: [Score at rest and on movement, where it is, and what is controlling it]
Nausea and vomiting: [None, or episodes, volume, and antiemetics given]
Eating and drinking: [What and how much: sips, clear fluids, part of a meal, a full meal]
Bowel function: [Flatus, bowel movement, or stoma output, and when each started; or none yet]
Urine: [Voiding, or catheter in place]
Walking: [How far, how often, and with whom]
Patient concerns: [What the patient raises today]

OBJECTIVE
Vital signs: [Temperature max, and 24-hour ranges for heart rate, blood pressure, breathing rate, and SpO2, with oxygen if any]
Intake and output: [IV and oral intake, urine in mL and in mL per kg per hour, nasogastric output, vomiting, net balance]
Drains: [Each drain by site: output in mL over 24 hours, the trend, and its character, such as serous, serosanguinous, bloody, bilious, or feculent; or none]
General: [Appearance, alertness, orientation]
Chest and heart: [Breath sounds, heart rate and rhythm]
Abdomen: [Distension, tenderness at the wound or beyond it, bowel sounds, guarding or peritonism]
Wound: [Dressing, edges, redness, swelling, discharge]
Stoma: [Color, swelling, output, or no stoma]
Calves: [Swelling or tenderness, or none]
Lines and tubes: [Each IV, central line, urinary catheter, nasogastric tube, or epidural, with its day number]

DATA
Labs: [Hemoglobin, white count, sodium, potassium, magnesium, phosphate, creatinine, CRP, against yesterday and the preoperative baseline]
Imaging and pathology: [New results, or what is pending]

MEDICATIONS
Pain relief: [Scheduled and as-needed medicines, and opioid doses used in 24 hours]
VTE prophylaxis: [Drug, dose, and start time; compression devices; or why not]
Antibiotics: [Drug, day number, and stop date; or none after surgery]
Home medicines: [Restarted or held, with the reason and the restart date]

ASSESSMENT
Summary: [Age, operation, postoperative day, and whether on track for this operation]
Problems: [Each problem, its status today, and the reason]

PLAN
Diet: [Advance, hold, or nothing by mouth, and why]
Fluids and electrolytes: [IV fluid rate, replacement, or stop; electrolytes to replace]
Lines, tubes, and drains: [What comes out today, and what stays and why]
Activity: [Walking goal, breathing exercises, physiotherapy]
Tests: [Labs or imaging ordered, and the reason]
Discharge criteria: [Each one, met or not yet: pain controlled on oral medicines, eating without vomiting, flatus, voiding, walking safely, no signs of a complication]
Expected discharge: [Date and destination]
Call the surgical team if: [Findings that need review, such as fever, a rising heart rate, falling urine output, or a change in drain fluid]

IMMEDIATE POST-OP CHECK
Time: [Date, time, and hours since leaving the operating room]
Patient now: [Alertness, pain, nausea, vital signs, urine since surgery, wound dressing, drain output]
Orders checked: [Diet, pain relief, fluids, VTE prophylaxis, antibiotics, against the operative note]
Plan: [Changes made, or no change]

Signed: [Name, credentials, date and time]