Patient: [Patient Name]
Date: [Date of Encounter]
I. Preoperative Diagnosis:
Reason for surgery (e.g., colon cancer, diverticulitis, inflammatory bowel disease)
II. Past Medical History:
Relevant medical conditions (comorbidities)
Previous abdominal surgeries (mention specifically those involving the colon)
Current medications (anticoagulants, antiplatelets)
Allergies (medications, anesthesia)
III. Operative Details:
Date of surgery
Surgeon performing the procedure
Anesthesia type (general, spinal)
Surgical approach (laparoscopic, open)
Specific procedure performed (e.g., colectomy with anastomosis, ileostomy creation)
Blood loss estimate
Drain placement (type and location)
Pathology report (if available): Briefly summarize key findings (e.g., tumor stage, lymph node involvement)
IV. Postoperative Day (POD):
Current POD (e.g., POD #1)
V. Vital Signs:
Temperature
Heart Rate
Blood Pressure
Respiratory Rate
VI. Pain Management:
Pain level (using a standardized scale)
Type of pain medication used
VII. Gastrointestinal Function:
Bowel sounds (present, absent)
Nasogastric tube (status, drainage)
Oral intake (started, type of diet)
Flatus (passed, absent)
Stool (passed, character)
VIII. Wound Care:
Dressing condition (clean, drainage)
Drain output (amount, character)
IX. Physical Exam:
General appearance (comfortable, distressed)
Abdominal exam (distention, tenderness)
X. Laboratory Studies (if available):
Briefly mention any relevant labs, like CBC or electrolytes.
XI. Differential Diagnoses:
Consider including any potential postoperative complications you are monitoring for (e.g., ileus, surgical site infection)
XII. Plan:
Diet advancement plan
Mobilization goals (out of bed, ambulation)
Pain management plan
Anticipated discharge date
Follow-up plan (outpatient clinic appointment)
Wound care instructions (dressing changes)
Medications (to continue at home)
Activity restrictions
XIII. Notes:
Include any additional relevant information, such as patient’s tolerance to procedure, need for additional procedures, or emotional state.
XIV. Dictated By:
Your Name and Title