Sample Notes

Pre-Ops Note

Date
Time

Pre-Op Diagnosis:
Planned Procedure and Scheduled Time:
Indication:
Labs/studies:

---/---/---{         }---{                  U/A                           LFT's

Official CXR reading: (on chart)
Official EKG reading: (on chart)
Type and Cross/Screen for __ units in blood bank
NPO after MN
IVF ordered after MN
Antibiotics ordered on call to OR:
Anesthesia evaluation (on chart)
Operative Consent (on chart) 

  • If any of the above are missing or incomplete, call an intern! 
  • All abnormalities and/or omissions must be addressed! 

Operative Note

Date
Time

Pre-Op Diagnosis: gallstone pancreatitis
Post-Op Diagnosis: same
Procedure: Laparoscopic cholecystectomy with Intraoperative cholangiogram
Surgeon: Lin
Assistants: Resident, MS
Anesthesia: GETA (General Endotracheal Anesthesia)
EBL: minimal
UOP (urine output): unmonitored (no foley) or amount
IVF: 2000 cc crystalloid
Findings: Intraabdominal adhesions, distended GB, +GS, cholangiogram: mildly dilated CBD, no filling defects, normal intrahepatic radicles, uninterrupted flow into duodenum
Specimens: GB to pathology
Drains: None
Complications: None
Disposition: To Recovery Room, extubated, in stable condition 

Surgery MS3 Progressive Note

Date
Time
Meds

POD#__ after ______________________________ Abx day #___

24hr events/subjective complaints
(Include presence or absence of nausea, vomiting, flatus, BM, ambulation, pain, chest pain, SOB, and other PERTINENT info.)

Vitals: Tmax, Tcurrent BP(range) HR(range) RR(range) Pox (if available)
I/O: Total In/Total Out
        8hr shifts - Ins broken down into IVF, PO, NGT, feeding tube, etc.
        8hr shifts - Outs broken down into NGT, U/O, stool, emesis, drains, etc.
PE: Lungs – CTA bil
       Heart – RRR, no M/R/G
       Abdomen – soft, ND/NT, normoactive BS
       Wound – well-approximated, no erythema or d/c
       Stoma – pink, patent, productive of stool
       Ext – no edema
        Labs (do not present orally if previously presented on rounds)
A/P: __ year old man/woman POD#___ after ______________________ progressing well
Neuro: Pain control adequate, continue PCA
             OOB, ambulate today
CV: Mild tachycardia, will bolus with 500cc isotonic crystalloid and reevaluate
       Resp: No issues, continue spirometry
GI: Await return of bowel function, continue NPO, NGT
GU: U/O marginal, continue to monitor closely after volume load
        Replete electrolytes
Heme: HCT 27 and stable, continue SQ Heparin
ID: Perioperative abx D/C'd, afebrile, check WBC today
Endocrine: Continue ISS, BS well controlled 

Surgery MS3 ICU Progressive Note

Date
Time

Significant 24hr events/road trips, subjective complaints (Ask the nurses!) 

Meds

Neuro: PE, GCS, sedative drips, pain control CV: PE/vasc exam (where appropriate)
             HR (range) BP (range) CVP (range)
             Cardiac parameters (if PA cath in place)
             CO                  CVP
             CI                    PCWP
             PAS/PAD         SVR
             SV

Resp: PE
           RR (range) Pox ___% on RA/___%FIO2
           Vent settings: mode, rate, TV, FIO2, PS, PEEP
           ABG: pH/pCO2/pO2/TCO2/BE or BD/sat on latest vent settings

GI: PE incl wound, diet/tube feeds, drains/NGT output, LFT's

Renal/FEN: 24hr I/O's including breakdown into component parts
                    IVF rate
                    UOP/hr (in cc/kg/hr)
                    Labs: ---/---/---{ Ca, Mg, PO4

Heme/ID: Tmax, Tcurrent Abx day#___
                 }---{ PT/PTT Cx results:

Endocrine: Accuchecks, Insulin dosing, TFT's, steroids

A/P: ICU Day#___, POD#___after____________________
        Neuro:
        CV:
        Resp:
        GI:
        Renal/FEN:
        Heme/ID:
        Endocrine: