Date: [Date of encounter]
Patient: [Patient Name]
Hospital Day: [Postoperative Day]
Chief Complaint: [Describe patient’s concerns related to SSI, e.g., wound drainage, redness, pain]
History of Present Illness:
Date of surgery and surgical procedure performed
Onset, duration, and progression of SSI symptoms (pain, redness, swelling, drainage)
Characteristics of wound drainage (color, amount, odor)
Recent changes in wound appearance or patient’s condition
Prior antibiotic use for suspected SSI
Past Medical History:
Underlying medical conditions (e.g., diabetes, chronic obstructive pulmonary disease)
History of previous SSIs
Allergies (medications and other)
Surgical History:
Relevant past surgical procedures
Social History:
Smoking history
Immunocompromised status
Physical Exam:
Vital signs (temperature, heart rate, blood pressure)
Wound site assessment:
Location
Size
Erythema (redness)
Induration (hardness)
Drainage (amount, color, character)
Dehiscence (wound separation)
General examination findings (e.g., fever, lymphadenopathy)
Laboratory Tests:
White blood cell count (WBC) and differential (elevated may indicate infection)
Wound culture results (identify specific organism causing the SSI)
Other tests as indicated (e.g., blood cultures, electrolytes)
Imaging Studies (if performed):
X-ray (assess for deep infection involving bone)
Ultrasound (evaluate for abscess formation)
CT scan (evaluate for deeper tissue involvement)
Assessment:
Type of SSI:
Superficial incisional (involves skin and subcutaneous tissue)
Deep incisional (extends to fascia and muscle)
Organ/space (involves deeper organs or body spaces)
Severity of SSI:
Mild (minimal drainage, localized erythema)
Moderate (purulent drainage, moderate erythema/induration)
Severe (extensive drainage, significant tissue necrosis, systemic signs of infection)
Possible causative organism(s) based on clinical presentation and wound culture results
Plan:
Wound Management:
Wound cleaning and dressing changes as needed
Debridement (removal of infected tissue) if indicated
Antimicrobial Therapy:
Selection of appropriate antibiotics based on culture results and local antibiotic resistance patterns
Duration of treatment based on severity of infection
Pain Management:
Medications to address pain and discomfort
Nutritional Support:
Ensure adequate nutrition to support healing
Physical Therapy:
As indicated to maintain mobility and prevent complications
Disposition:
Continued hospitalization for treatment and monitoring
Discharge home with outpatient follow-up and wound care instructions
Follow-up:
Schedule outpatient follow-up appointments to monitor wound healing and adjust treatment plan as needed
Coordinate with referring physician (if applicable)
Additional Notes:
Include any additional relevant information not covered in the above sections.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the management of SSIs.