Pediatric Surgery Postoperative Check Note

Date/Time of Evaluation: [Evaluation date and time] (Use actual bedside evaluation time, not note creation time.)

Location: [PACU / PICU / NICU / Floor]

POD: [Postoperative day number]

Weight (kg): [Most recent weight in kg]

Procedure: [Procedure name, laterality/site, indication, operative date]

Surgical Team: [Attending surgeon, assistants, service]

Risk Factors: [Patient-specific monitoring considerations] (Include only if present—e.g., prematurity with corrected age, OSA, congenital heart disease; omit line if none.)

Operative Summary

[Concise intraoperative course focused on immediate post-op management] (Use a short paragraph or brief bullets. Include key findings relevant to complication surveillance, significant intraoperative events, clinically meaningful EBL, and lines/drains/tubes placed with locations. Reference operative and anesthesia records for complete details. If specific information is not yet available, state that it will be obtained from those records.)

Post-Op Course

[Interval narrative from end of surgery to current evaluation] (Cover transport/arrival status, pain control and scale used, nausea/vomiting, mental status/awakening, and any notable events. Use objective behavioral descriptors for preverbal children.)

• Pain: [Pain assessment tool, score, adequacy of control, recent analgesics and response]
• Symptoms/Observations: [Nausea/vomiting, respiratory status, voiding, caregiver concerns] (Include patient/caregiver input when available.)
• Subjective not obtained because: [Reason] (Include only if applicable—e.g., sedated, intubated, developmental status, no caregiver present.)
• Notable events: [Events since arrival] (Include only if occurred—e.g., desaturation episodes, bleeding, hemodynamic changes.)

Objective

• Vital signs: [HR, BP, RR, SpO2, Temp with pertinent trends]
• Respiratory support: [Room air / Nasal cannula / HFNC / NIV / Ventilator with settings as applicable]
• Intake/Output: [IV fluids and rates]; [Urine output]; [Drain outputs with character]; [Other outputs as relevant]
• Focused exam:
  • General: [Appearance, level of distress, comfort]
  • Respiratory: [Work of breathing, breath sounds, airway patency]
  • Cardiovascular: [Pulses, capillary refill, perfusion]
  • Operative site: [Dressing status, site appearance if visible, tenderness, swelling]
  • Lines/Drains: [Type, location, securement, patency, output character]
  • Neurologic: [Arousal, age-appropriate interaction, movement]
• Data: [Pertinent labs or imaging already resulted] (Note pending studies and action thresholds.)

Assessment

[One-sentence stability statement addressing hemodynamics, respiratory status, and pain control adequacy]

• [Primary postoperative problem]: [Link operation to current status; summarize active concerns]
• [Additional active problem]: [Status and immediate needs] (Include only if applicable.)

Plan

• Disposition/Monitoring: [Location, level of care, monitoring requirements] (Specify continuous pulse oximetry or apnea monitoring for infants/ex-preterm/OSA patients.)
• Respiratory: [Oxygen titration/weaning parameters, airway precautions, extubation plan if intubated]
• Fluids: [IV fluid type and rate, UOP goal, bolus criteria]
• Pain/Comfort: [Multimodal analgesia plan with opioid monitoring expectations] (Reference weight-based order sets rather than duplicating doses.)
• Diet: [NPO / clear liquids / regular diet]; [Advancement criteria]; [NPO rationale if applicable]
• Antibiotics: [Agent, indication, duration/stop criteria] (State if none indicated.)
• Wound/Drain care: [Dressing management, drain criteria, catheter plan]
• Activity: [Bedrest / up with assistance / restrictions]
• Labs/Imaging: [Tests to obtain with timing and action thresholds]
• Call parameters: [Specific changes prompting notification] (Tailor to patient and operation—e.g., increased bleeding, desaturation, apnea, hemodynamic instability, inadequate UOP.)
• Follow-up: [Next surgical reassessment, contact for urgent issues]

Complications to Monitor

• [Bleeding/hematoma]: [Monitoring signals—e.g., increasing dressing saturation, tachycardia, rising drain output]
• [Respiratory depression/apnea]: [Signals—desaturation, bradypnea, apneic episodes] (Higher risk in infants and ex-preterm patients.)
• [Airway obstruction]: [Signals—stridor, retractions, difficulty maintaining SpO2]
• [Procedure-specific complication]: [Name and early signals] (Include only those plausible for this case.)
• [Infection]: [Early signals—fever, erythema, purulent drainage]

(Reference operative and anesthesia records rather than reproducing them. Do not copy forward pre-operative exam findings. If critical information is unknown, state the plan to obtain it.)