Postoperative Check Note (Student)

Date and time of note: [Date and time]

Postoperative day: [POD #0 / POD #1 / POD #2 / POD #3+]

Procedure performed: [Procedure name] (per OR record / per team sign-out)

Service and attending surgeon: [Service] — [Attending surgeon]

Author: Medical Student, [Name, contact]

Patient location: [PACU / floor / ICU / step-down]

Surgical Context

[Relevant intraoperative factors affecting immediate care, with source attribution] (Include only if intraoperative factors directly affect current management. If not relevant, omit this section entirely.)

Subjective

(If patient is intubated, sedated, or otherwise unable to participate, write: "Unable to obtain subjective due to [reason]" and proceed to Objective.)

• Pain: [Location, severity, character, response to current regimen]
• Nausea/vomiting and PO tolerance: [Presence/absence of nausea or emesis; tolerance of current diet]
• Cardiopulmonary symptoms: [Presence/absence of shortness of breath, chest pain]
• GI status: [Flatus/bowel function, abdominal distension as appropriate to POD]
• GU status: [Voiding spontaneously / Foley in place; retention symptoms if applicable]
• Mobility: [OOB to chair / ambulation status; orthostatic symptoms present/absent]

Objective

(Document only what you verified or reviewed. State source when using charted data. Do not include autopopulated normals.)

• Vitals: [Most recent vitals with relevant trends; O2 device and requirement]
• I/O: [Intake/output summary; urine output rate] (Include when clinically relevant. If pending, state so with plan to reassess.)
• Drains/Tubes: [Type, location, output amount and character since OR] (Omit if none present.)
• Labs/Imaging: [Reviewed results that impact decisions] (If pending, state with follow-up plan.)
• Exam:
  • General/Mental status: [Alertness, comfort, orientation]
  • Respiratory: [Work of breathing; auscultation if performed]
  • Cardiovascular: [Heart rate/rhythm if assessed; peripheral perfusion]
  • Surgical site: [Dressing status; drain sites; hematoma or bleeding present/absent]
  • Extremities: [Neurovascular exam if relevant to procedure] (Omit if not applicable.)

Assessment

One-line summary: [POD#] s/p [procedure] — [current clinical status: hemodynamic stability, pain control, diet tolerance]

• Active issue 1: [Problem with severity: stable / improving / concerning / unstable]
• Active issue 2: [As above]

(Include only immediate postoperative issues. For instability or high-risk findings, document who was notified and when. Add items as needed; do not list chronic conditions unless affecting current management.)

Plan

(Organize by active problems, prioritized by acuity. Omit domains that do not apply.)

• Hemodynamics/Fluids: [Resuscitation strategy; maintenance fluids; monitoring plan]
• Pain management: [Multimodal regimen; PRN parameters; bowel regimen]
• Pulmonary: [Oxygen weaning plan; incentive spirometry; pulmonary hygiene]
• Diet: [Current diet order; advancement criteria]
• GU: [Voiding trial timing; Foley plan; urine output goals]
• Wound/Drains: [Dressing care; drain management; monitoring for complications]
• VTE prophylaxis & mobility: [Mechanical/pharmacologic prophylaxis; ambulation orders; PT/OT if indicated]
• Antibiotics: [Prophylaxis stop time; therapeutic antibiotics if applicable] (Omit if not applicable.)
• Disposition: [Current level of care; criteria to transfer/upgrade; next reassessment time]
• Escalation parameters: [Specific thresholds to call team: vital signs, urine output, bleeding, respiratory or mental status changes]

Signature (Medical Student): [Name, year, contact, date/time]

Supervising clinician verification: [Resident/Attending name and credentials] — [Attestation/co-signature]