Postoperative Check Note (Vascular Surgery)

Date/Time: [Date and time of note]

Location: [PACU / ICU / Step-down / Ward]

POD #: [0 / 1 / …]

Procedure: [Procedure name with laterality when applicable]

Disposition: [Current level of care] → [Planned level of care]

Clinical Context: [Single-sentence summary of procedure, indication, current location, and stability statement]

Procedure Highlights

Anesthesia/Airway: [Anesthesia type]; current airway [extubated / intubated] on [oxygen delivery method]. Access Sites: [Locations, sizes, closure method]. Intraop Anticoagulation: [Agent, dose, reversal status]. EBL/Transfusion: [Volume and products if significant]. Contrast: [Volume if applicable]. Intraop Events: [Relevant complications or "No intraoperative complications reported"]. Interval Events: [Events since OR or "No interval events since procedure end"].

Subjective

[Patient-reported symptoms including pain score and location, nausea/vomiting, limb symptoms such as numbness, tingling, weakness, coldness, or pain out of proportion; for cerebrovascular procedures include headache, visual changes, speech difficulty] (If patient cannot participate due to sedation, intubation, or delirium, state the reason explicitly rather than documenting negative responses.)

Objective

Vitals: BP [value] | HR [value] | RR [value] | SpO2 [value]% on [oxygen delivery] | Temp [value] | Vasoactive support: [none or agent/dose]. Level of consciousness: [alert / drowsy / sedated].

Exam: (Document only what was examined.)

• General: [Appearance, distress level, orientation]
• Access Sites/Incisions: [For each site: location, dressing status, hematoma presence/size/trend, ecchymosis, distal perfusion] (If limited by dressings, state explicitly.)
• Operated Limb Neurovascular: [Side]: Color [value], temp [value], cap refill [value] sec, pulses [palpable / Dopplerable with quality at specified arteries], sensation [intact / impaired], motor [intact / weak]. Compared to [contralateral limb / preoperative baseline]. (If limited by regional anesthesia, state explicitly.)
• Neurologic (CEA/CAS only): Alertness [value], speech [value], facial symmetry [value], gross motor [RUE/LUE/RLE/LLE], neck [swelling/hematoma assessment].

Data: [Hgb/Hct if bleeding concern; Cr if contrast/renal risk; lactate if perfusion concern; relevant imaging reviewed] (Include only decision-relevant results.)

Assessment and Plan

(Organize by problem, prioritized by acuity. Include assessment statement, plan, monitoring frequency, and specific notify parameters.)

Hemodynamics: [Assessment]. BP goal [range]. Plan: [fluids/vasoactives/transfusion threshold]. VS q[frequency]. Notify if: [specific BP/HR thresholds, new arrhythmia, acute change].

Bleeding/Access Site: [Assessment]. Care: [pressure dressing/bedrest duration/sheath protocol]. Site checks q[frequency]. Notify if: expanding hematoma >[threshold], persistent bleeding, hemodynamic change, signs of retroperitoneal bleed if femoral access.

Neurovascular Status: [Assessment vs baseline]. NV checks q[frequency]. Pulse monitoring: [method and arteries]. Notify if: pain out of proportion, pallor/coolness, loss of Doppler signal, new numbness/weakness, tense compartments. Compartment syndrome vigilance: [specific instructions if reperfusion case].

Neurologic (CEA/CAS): [Assessment]. Neuro checks q[frequency]. BP parameters: [targets with rationale]. Notify if: new headache, visual change, speech difficulty, focal deficit, neck swelling/stridor.

Pain/Nausea: [Analgesia regimen]. Antiemetics: [agents PRN]. Bowel regimen if opioids.

Anticoagulation/VTE Prophylaxis: [Post-op anticoagulation/antiplatelet plan with timing]. VTE prophylaxis: [mechanical/chemical and start time].

Renal (if contrast exposure): Contrast [volume]. Mitigation: [hydration, avoid nephrotoxins, Cr recheck timing].

Disposition: [Current location] → [transfer criteria/timing]. Next checkpoint: [time or milestone]. Diet/activity: [instructions]. Follow-up labs/imaging: [tests and timing].

Communication

[Who was updated and key concerns/contingency plans communicated].