Inpatient Daily Progress Note (Vascular Surgery)

Date/Time: [Date and time of note]

Author: [Author name, role; supervising attending if applicable]

Patient: [Patient identifier per local policy]

Location: [Unit/bed]

Service: [Vascular Surgery - primary / Vascular Surgery - consult]

Hospital Day / Post-Op Day: [HD#X / POD#Y s/p procedure and date] (For non-operative patients, output only HD#. If procedure details unknown, note "Procedure/date: unknown (chart review pending)")

Code Status: [Code status]

One-Liner

[One to two sentences: patient archetype, primary vascular condition or recent procedure, key comorbidities impacting today's decisions, current status, and most pressing active issue]

Interval Events

[Material changes in last 24 hours: hemodynamic/respiratory events, bleeding/transfusions, anticoagulation changes, procedures, new results, mobility milestones, delirium] (Omit section entirely if no significant events. If events unknown due to recent transfer, state reason.)

Subjective

[Patient-reported symptoms relevant to vascular care: limb symptoms, wound concerns, cardiopulmonary symptoms, functional status] (If unable to obtain, document reason and capture observations in Objective.)

Objective

Vitals/I&O: [Recent vitals with trend; 24-hour intake/output and net balance] (Note if data incomplete.)

Drains/Wounds/Lines: [For each drain: output volume in mL and character; wound VAC settings and output; incision/wound appearance and dressing status; indwelling lines/catheters with type, day in place, and whether still indicated] (Quantify drain output; avoid vague terms without numbers.)

Labs/Imaging: [Pertinent abnormal values, key trends, and new imaging findings with clinical implication] (Do not reproduce full reports.)

Exam: [Problem-focused exam including vascular/extremity assessment: limb temperature, color, capillary refill, pulses with method (palpable vs Doppler) and location, edema, compartment tension, motor/sensory function; access site evaluation for hematoma/bleeding/pseudoaneurysm; incision status; brief cardiopulmonary and abdominal exam as indicated] (If element cannot be assessed, document reason.)

Assessment & Plan

(Organize by active problems in order of acuity. For each problem: 1–2 line assessment with supporting data, then bulleted plan items beginning with action verbs. Omit chronic stable problems without active plan.)

[Problem label]

[Assessment of current status with key supporting data]

• [Plan items: medications with dose/target/monitoring, diagnostics, monitoring parameters, procedures, consultations, contingencies as relevant to this problem]

(Repeat for each active problem. Common vascular domains when active: index vascular condition/post-op state; perfusion monitoring; wounds/drains/access sites; anticoagulation/antiplatelet strategy with indication, agent, target, and hold parameters; infection; pain; cardiopulmonary; renal/contrast; VTE prophylaxis; nutrition; mobility; line necessity.)

Disposition

[Anticipated discharge timing and destination; primary barrier to discharge; next step to resolve]

[Family communication, goals-of-care discussions, or safety-critical instructions if applicable] (Omit if none.)