How to Write a Surgery Post-Op Progress Note

A postoperative surgery progress note is a medical record that documents the patient's recovery progress after a surgical procedure.

The purpose of the progress note is to document the patient's condition, including vital signs, pain level, and any other significant changes or events.

The postoperative progress note typically includes information on:

• patient's surgical procedure including the type of surgery, the date and time of the procedure, and any pertinent details about the surgical technique or approach.

• patient's recovery, such as their level of pain, any complications that have arisen and patient's response to treatment.

Additionally, the progress note may include:

• orders for medication, laboratory tests, or other diagnostic procedures,

• any recommended follow-up care or rehabilitation.

This information is critical for continuity of care and ensuring that the patient receives appropriate treatment and monitoring during their recovery period.

Post-Op Progress Note Template

A surgery progress note (when rounding on your patients) should follow the SOAP format and include the following information:

• ID: post op day (POD) # (number of days from surgery), reason for admission, surgery performed

• Subjective: problems identified overnight by the patient and overnight nursing staff (such as changes in vital signs, pain, or complications)

  • Diet: This refers to the patient's current dietary status and any restrictions or modifications that have been made

  • Pain/analgesia: This refers to the patient's level of pain and the medications being used to manage it

  • Urine output: This refers to the amount of urine the patient is producing, which can be an indicator of fluid balance and kidney function

  • GI function (flatus/BM): This refers to the patient's gastrointestinal function, specifically whether they have been passing gas or having bowel movements

• Objective:

  • Focused physical exam: This includes a targeted physical examination to assess the patient's current condition. Comment on surgical incision site, dressing.

  • New labs/imaging: Any new laboratory tests or imaging studies that have been ordered or obtained should be documented

• Assessment and Plan: Your overall assessment and current management plan. This refers to the current plan for the patient's care, including any changes that have been made since the last rounding.

Example Post-Op Surgery Progress Note for a General Surgery Patient

GENERAL SURGERY

ID: 54M POD#2 Lap Cholecystectomy for acute cholecystitis (DOS: January 15, 20__ by Dr. ___)

S:
- Mild incisional pain, well controlled with Acetaminophen
- No nausea/vomiting
- Diet returned to baseline
- passing gas, and BM earlier today
- Urinary output adequate

O:
On exam:
AVSS
- Incision clear, dry, intact - with no signs of infection
- No erythema, drainage or tenderness
- Bowel sounds present in all four quadrants
- Able to WBAT without assistance

Ix: Hb 104 (pre-op 120). Lytes otherwise normal.

A/P: Recovering well.

1. Pain: Continue Acetaminophen PO for pain

2. Activity: Continue WBAT

3. Diet/Fluids: Increase fluid intake as tolerated

4. Disposition: Discharge home in 1 day. Follow-up in clinic 2 weeks post-op for stitch removal and re-assessment

Jane Langhorn, PA-S2
Clinical Clerk, Orthopaedic Surgery

In service of: Dr. ______