Post Operative Note
The post-op check and the daily note that follows it.
Surgery performed.
Patient comments or complaints, nursing comments. Check the level of consciousness (alert, oriented, drowsy), pain control, whether they have passed gas, urine output, bowel movements, chest pain and shortness of breath.
Vitals: blood pressure, pulse, respirations, temperature, oxygen saturation.
Ins and outs: IV fluid, oral intake, emesis, urine, stool, drains.
Exam: physical findings, including the incision and dressing and the neurovascular status.
Labs: results of anything sent since surgery.
Assessment based on the data above.
Medication changes, lab tests, procedures, consults, discharge planning.
Take the dressing down and look. A note that says the dressing is clean, dry and intact tells you about the dressing, not about the patient underneath it.