Neurosurgery Daily Progress Note (Inpatient)

Date/Time: [Date and time of note entry]

Author/Service: [Clinician role and service/team]

Location: [Unit/room; ICU vs floor]

HD# / POD#: [Hospital day] / [Post-op day relative to primary index procedure] (If unknown, write: unknown (verify).)

Primary Diagnosis: [Primary neurosurgical diagnosis]

Consult Status: [Consulting for whom, reason, and follow-up vs sign-off consideration] (Include only if this is a consult note.)

One-Liner

[Age/sex], [HD#/POD#], [primary procedure or diagnosis], neurologic status [stable / improving / worsening] with [key deficit if any], [device status if present], 24-hour trajectory [improved / unchanged / declined]. (Output as a single sentence.)

Interval / Subjective

Interval events: [Significant events since last neurosurgery note: neuro changes, hemodynamic issues, procedures, device events, new imaging, infection concerns, consult updates] (If no significant events, state: No acute neurosurgical events overnight.)

Patient-reported symptoms: [Relevant symptoms: headache, nausea, vision/speech changes, weakness/numbness, pain, spine/radicular symptoms as applicable] (Limit to 2–5 sentences. If limited by intubation, sedation, or altered status, state the limitation and information source. Do not include full review of systems.)

Objective

Vitals: [Current vital signs including ICP/CPP if neurocritical; note BP/MAP goal if ordered] (Do not carry forward prior values.)

Devices/Drains: (Required when present; add one entry per device.)

• [Device type with laterality/site]: [status: open / clamped / suction], [current setting with reference level], [output amount and timeframe], [appearance], [site integrity], [changes today] (If parameters unavailable, write: verify with bedside RN. Never carry forward prior values.)

Neuro Exam: (Required daily. State limitation if exam restricted by sedation, intubation, or cooperation. Omit elements not examined.)

• Mental status: [Arousal, orientation, command following, speech/language]
• GCS: [E/V/M components] (Include when indicated: ICU, trauma, decreased LOC.)
• Pupils: [Size in mm, symmetry, reactivity]
• Cranial nerves: [EOMs, facial symmetry, other relevant CNs]
• Motor: [Strength by extremity 0–5, drift if assessed]
• Sensory: [Light touch; dermatomal if spine-focused]
• Coordination/Gait: [Findings] (Include only if assessed.)

Data: [Pertinent labs with trend if relevant] [New imaging: date, modality, key findings, comparison; specify personally reviewed vs report reviewed] (If no new imaging, state so. Include only results referenced in the plan.)

Assessment & Plan

(Number problems in descending severity. For each problem: brief assessment statement followed by actionable plan items with explicit thresholds and time anchors.)

1. [Primary neurosurgical problem with laterality/level]

[Current status and trajectory assessment]

• [Plan items as relevant: neuro monitoring with escalation triggers, device/drain management with wean/removal criteria, imaging timing, BP/MAP/ICP targets, seizure prophylaxis, VTE/antithrombotic plan, infection management, pain/sedation, mobility/precautions, disposition]

2. [Additional problem]

[Brief assessment]

• [Plan items]

(Add numbered problems as needed. For consult notes: clarify what neurosurgery manages vs defers to primary team; state sign-off criteria and timeframe.)

(Do not infer diagnoses or data not explicitly stated. If management depends on pending results, document explicit contingencies.)