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: