Postoperative Note



Procedure: [Surgery Performed]
S: Pt comments or complaints, nursing comments, CHECK consciousness (alert, oriented, drowsy), pain control, etc.
O: Vitals: Temp, BP, Pulse, RR, O2 Sat
    In/Out: IV Fluids, PO intake, Emesis, Urine, Stools, Drains etc
    Exam: Physical findings (Incision/dressing, Neurovascular status, etc.)
    Meds: If there are any new medications added.
    Labs: New Labs

A/P:
  - Assessment based on data -- Your management, recommendations by surgeon.