PostOp Notes

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PostOp Notes

Surgical Follow-Up

Patient

Vitals & I/O

Labs

Examination

Recommendations

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🏥 Patient Information

Full Name

Date

POD (Post-Op Day)

Diagnosis (Dx)

History (Hx)

🌡️ Vital Signs

Temp (°C)

Pulse (bpm)

BP (mmHg)

RR (breaths/min)

SpO₂ (%)

💧 Fluid Balance & I/O

Ryle (NG) Output

UOP (Urine Output)

Fluid Balance (Total In/Out)

Drains (Description / Output)

🔬 Laboratory Results

Complete Blood Count

Hgb (g/dL)

WBCs (×10³)

Plt (×10³)

Liver Function

SGPT (ALT)

SGOT (AST)

Bill. Total

Bill. Indirect

Bill. Direct

Metabolic Panel

S.Alb (g/dL)

S.Cr (mg/dL)

Na⁺ (mEq/L)

K⁺ (mEq/L)

Mg²⁺

Ca²⁺

Inflammatory & ABG

CRP (mg/L)

Pro-Cal (ng/mL)

pH

HCO₃ (mEq/L)

CO₂ (mmHg)

🩻 Physical Examination

Chest

Abdomen

Bowel Sounds

Flatus/Pass

Yes No

Nutrition

NPO Clear Fluids Soft Diet Full Diet

Stoma

Wound

Bed Sores

Fistula

Antibiotics

Anti-Coag.

📝 Recommendations & Plan

Recommendations

Plan / Notes

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Patient Actions