Postoperative Check Note (PACU/POD 0)

Date/Time: [date and time of note]

Location: [PACU / Floor / ICU]

POD: [0 / immediate post-op]

Procedure: [procedure name with laterality/site if applicable]

Surgeon: [name, credentials]

Anesthesia Type: [general / regional / MAC / unknown]

Post-op Summary: POD 0 s/p [procedure] for [indication], hemodynamically [stable / unstable], pain [controlled / uncontrolled], [nausea/vomiting present / absent], [dressing/drain status]. [key intraoperative facts affecting immediate management] (Only include intraoperative details that change immediate management: significant EBL, complications, implants affecting monitoring, regional blocks/catheters.)

Subjective

[Mental status and ability to participate in assessment] (State alertness/orientation and ability to provide history. If unable to participate, document reason and reassessment plan with timeframe.)

Pain: [pain score (0–10), location, character, response to interventions]

Nausea/Vomiting: [presence/absence, emesis episodes, antiemetics given and response]

Other Symptoms: [respiratory symptoms, neurovascular complaints, bleeding sensation, urinary symptoms, other concerns] (Include only if reported; use direct quotes for statements that change clinical urgency.)

Objective

Vitals: [current vital signs] | [trend/range since arrival] | [oxygen delivery and SpO2] (If not assessed, state "not assessed" with reason and plan.)

I/O: [IV fluids administered], [urine output with timeframe and Foley status], [drain output with character if applicable]

Exam: (Tailor to procedure; if a component was not assessed, explicitly state "not assessed" with reason and plan.)

• General: [appearance, level of distress]
• Airway/Respiratory: [work of breathing, breath sounds]
• Cardiovascular: [rate/rhythm, perfusion]
• Abdomen: [soft/firm, tenderness, distention] (Include only if relevant to procedure.)
• Surgical site: [dressing integrity, bleeding/hematoma, wound edges if visible]
• Neurovascular: [pulses, cap refill, motor, sensory by specific distribution] (Document specific elements rather than non-specific "NVI." Include only if procedure-relevant.)
• Lines/Drains: [type, site, function, securement]

Data: [pertinent labs with values], [imaging findings], [pending studies with expected timing] (List pending studies separately from completed results.)

Assessment

[Brief synthesis addressing hemodynamic stability, respiratory status, pain/PONV control, and complication concerns (bleeding, respiratory compromise, neurovascular changes). If abnormalities present, state leading concern and rationale.] (Do not restate Objective details; provide concise interpretation tied to current risks.)

Plan

• Pain management: [multimodal regimen, PCA/nerve block details if applicable, rescue criteria]
• PONV: [antiemetic strategy, rescue options]
• Respiratory/Oxygen: [oxygen plan, SpO2 goal, weaning strategy, incentive spirometry]
• Fluids/Renal: [IVF type/rate, UOP goals, transfusion thresholds, Foley plan]
• Wound/Drain care: [dressing management, drain output recording frequency, removal criteria]
• Neurovascular checks: [frequency and parameters] (Include only if procedure-relevant.)
• VTE prophylaxis: [mechanical method] and [pharmacologic agent with timing or contraindication]
• Antibiotics: [agent, indication, stop time] (Include only if indicated.)
• Diet: [NPO / clear liquids / advance as tolerated / therapeutic diet]
• Activity: [bedrest / ambulate with assist / weight-bearing status, PT/OT if indicated]
• Disposition: [PACU to floor / ICU / step-down / discharge criteria]

Contingencies: (Specify thresholds, who to notify, and actions.)

• [Vital sign thresholds] → [notify] and [actions]
• [Respiratory worsening: increasing O2 needs, sedation/apnea] → [notify] and [actions]
• [Bleeding: wound saturation, drain output > threshold] → [notify] and [actions]
• [Neurovascular decline: new weakness, numbness, loss of pulses, escalating pain] → [notify] and [actions]
• [Oliguria or urinary retention] → [notify] and [actions]
• [Uncontrolled pain or refractory PONV] → [notify] and [actions]

Pending Items: [labs/imaging awaited with timing], [scheduled reassessments with timing], [medication efficacy rechecks]

(If any element was not assessed, explicitly state "not assessed" with reason and plan rather than omitting. Do not document normal findings unless directly examined or attributed to source.)