Inpatient Daily Progress Note (Oral and Maxillofacial Surgery)

Date/Time: [Date and time] | Service: [OMFS Inpatient Service] | Author/Role: [Name, credentials, role] | Attending: [Attending surgeon] | Location: [Unit/bed]

HD/POD: [Hospital day and/or post-op day] | Primary Dx/Procedure: [Primary diagnosis and/or index procedure][ | Code Status: [Code status]][ | Allergies: [Allergies impacting current care]][ | Diet/Airway: [Diet status and/or airway considerations]] (Include Code Status, Allergies, and Diet/Airway fields only when actively relevant to today's care—e.g., trach, wired jaw, NPO for OR. Omit fields and preceding separators if not relevant.)

One-Liner

[1–2 sentence synopsis capturing HD/POD, procedure, current trajectory, and next key milestone]

Assessment & Plan

[Global assessment] (Optional 1–2 sentences summarizing overall trajectory and anticipated timeline.)

[Problem 1 (highest acuity)]: [Brief status]

• Today: [What changed since yesterday]
• Plan: [Actionable steps for today] (For infection/antibiotics: include drug, day of therapy, culture status, and de-escalation/stop date.)
• Disposition impact: [How this affects discharge timing]

[Problem 2]: [Brief status]

• Today: [Key interval changes]
• Plan: [Focused actions for this problem]
• Disposition impact: [Implications for discharge]

(List only active problems in descending order of acuity. OMFS domains to consider: airway/respiratory; primary diagnosis/post-op care; infection/antibiotics; wounds/drains; occlusion/fixation; cranial nerve/neurosensory status; pain; nutrition. Remove unused problem blocks.)

Disposition: [Expected discharge timeframe, barriers, required services/equipment, and follow-up]

Subjective

• Interval events: [Overnight events, fevers, procedures, consult updates] (If none: "No acute events overnight.")
• Symptoms: [Patient-reported pain (location, control), swelling progression, bite/occlusion changes, neurosensory symptoms (lip/chin numbness, facial weakness), respiratory symptoms, oral intake tolerance] (Include pertinent OMFS symptoms; quote patient when helpful for occlusion assessment.)

Objective

• Vitals: [Tmax, HR range, BP range, SpO2/O2 requirement—summarize trends]
• Lines/Drains/Airway: [Device type, location, day in place, output/character; airway specifics if applicable] (If none: "None.")
• Data: [Pertinent labs, imaging, cultures with interpretation] (For microbiology: collection date, gram stain, growth to date.)
• Exam:
  • General/Airway: [Appearance, work of breathing, voice quality, oxygenation]
  • Face/Head/Neck: [Swelling location/degree, tenderness, fluctuance; maximal interincisal opening in mm if trismus present]
  • Intraoral: [Incision status, occlusion stability, arch bars/elastics/MMF status, oral hygiene]
  • Cranial nerves: [V2/V3 sensation, CN VII motor function] (Include when relevant to diagnosis.)
  • Wounds/Drains/Flaps: [Incision appearance, drain output; flap perfusion if reconstructive]
  (Physical exam must reflect today's assessment. If any element not assessed, document "Not assessed—[reason]" rather than omitting or copying forward.)