Bariatric Surgery Inpatient Daily Progress Note

Header

Date/Time: [Date and time of service]

POD/Procedure: [Post-operative day (POD #)] — [Procedure performed] ([Date of surgery])

Weight/BMI: [Current weight and BMI]

Key Comorbidities: [OSA/CPAP status; diabetes management; anticoagulation/antiplatelet status; other relevant comorbidities] (Include only items impacting today's management.)

Interval Events

• [Overnight course and significant changes since last evaluation] (Use brief bullets. Include new clinical events such as fever, tachycardia, hypoxia, emesis; milestone achievements such as first ambulation, PO intake, flatus/BM, Foley removal; and any new consults or interventions.)

(If no significant events, replace with a single line documenting an uneventful night. If overnight information is unavailable, state explicitly.)

Subjective

• Pain: [Location; severity; response to current regimen]
• Nausea/Vomiting: [Presence/absence; episodes; response to antiemetics]
• PO Tolerance: [What was attempted; approximate volume; tolerance/intolerance symptoms]
• GI Function: [Flatus/BM status]
• Mobility/Ambulation: [Distance; assistance level; frequency]
• Voiding: [Spontaneous vs catheter; difficulties]
• VTE Warning Symptoms: [New leg pain/swelling; chest pain; dyspnea] (Include only if present.)
• Discharge Readiness: [Patient's perception and stated barriers]

(Omit any symptom domains not assessed. Do not include a full review of systems.)

Objective

Vitals: [Range-plus-current vitals with oxygen support status] (Format as: "Tmax X; HR X–Y, now Z; BP X–Y/A–B, now C/D; RR X–Y; SpO2 X–Y% on [RA / NC / CPAP / BiPAP]")

I/O (24h): [PO intake; IV fluids; urine output; drain output if present; net balance] (Comment on urine output adequacy if concerning. If not recorded, state explicitly.)

Exam:

• General: [Appearance; comfort level; hydration status]
• Cardiopulmonary: [Work of breathing; breath sounds; heart rate/rhythm]
• Abdomen: [Distension; tenderness; guarding/rebound; bowel sounds]
• Incisions: [Clean/dry/intact vs erythema/drainage; dressing status]
• Drains: [Location; output character; insertion site appearance] (Include only if present.)
• Extremities: [Calf tenderness; edema; asymmetry] (Include only if VTE concern.)

(Document only elements actually examined.)

Data:

• Labs: [Abnormal values and pertinent trends] (If no new labs, state "No new labs; prior results reviewed.")
• Imaging: [Single-line impression] (Include only if performed or reviewed today.)

Assessment

[2–4 sentence synthesis stating POD#, procedure, whether recovery is expected or complicated, and current physiologic stability. Explicitly identify active concerns requiring monitoring or intervention, such as tachycardia out of proportion to pain, escalating oxygen needs, dropping hemoglobin, or persistent vomiting.]

Plan

• Post-op Care/Diet: [Current diet stage: NPO / clear liquids / bariatric stage X; progression plan; monitoring parameters including HR trend, fever curve, abdominal exam, PO tolerance, drain output]

• Pain: [Current multimodal regimen; changes today] (Goal: pain controlled to enable ambulation and adequate PO intake. Note sedation monitoring if OSA.)

• Nausea: [Antiemetic strategy; hydration plan] (If persistent vomiting, outline escalation/diagnostic plan.)

• Fluids/Nutrition: [IVF rate or hep-lock status; PO intake goals; electrolyte repletion if needed]

• Pulmonary/OSA: [Oxygen wean plan with target SpO2; CPAP/BiPAP plan; incentive spirometry and ambulation expectations] (Include only if OSA or oxygen requirement.)

• VTE Prophylaxis: [Mechanical: SCDs, ambulation frequency] [Chemical: agent, dose, frequency] [If held: contraindication and reassessment timing] [Extended prophylaxis plan at discharge if applicable] (Must document daily.)

• Wounds/Drains: [Drain output and character; removal criteria and anticipated timing] (Include only if drains present.)

• Glycemic Management: [Monitoring frequency; insulin or medication plan; glucose targets] (Include only if diabetes or stress hyperglycemia.)

• Discharge Planning: [Anticipated discharge date; remaining barriers; education status; follow-up appointments; home equipment needs]

Electronic Signature: [Clinician name, credentials, date/time]

Teaching Physician Attestation: [Attestation confirming personal participation and agreement with documented findings and plan] (Include only if required per institutional policy.)