Postoperative Checklists

• Date/time
• Postoperative Check S.O.A.P

  Subjective

  Note any patient complaints, diet tolerance, adequacy of analgesia

  Objective

  • General appearance
  • Vitals pulse, temperature, BP, respiratory rate
  • Input and Output
  • Physical examination chest, lung, abdomen, wound, legs
  • Wound examination check for excessive drainage or bleeding, skin necrosis and condition of drains
  • Drainage volume volume and characteristic
  • Labs

  Assessment

  assess the patient's overall condition, improvement, static or deterioration.

  Plan

  Reinforce preoperative instructions e.g. incentive spirometry, breathing exercises. Comment on abnormal labs, discuss treatment and discharge plans

The same applies to progress notes on daily patient management. Record the number of days post surgery, form a problem list- e.g. confusion, temperature, excess drainage etc. Comment on patient's status both subjective and objective, not forgetting to assess mobility and nutrition. Give clear instructions of proposed plans.