Surgery Progress Note (SOAP)

Surgery Progress Note

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

Author/Role: [Author name and credentials/role]

Service: [General Surgery / Trauma/ACS / Surgical Oncology / Vascular / Colorectal / Other]

Attending: [Attending surgeon name]

Clinical Context: [Procedure name, date, and POD # if post-operative; OR primary diagnosis and Hospital Day # if non-operative] (Omit POD/HD if not applicable.)

Summary: [One-sentence anchor: age/sex, POD or HD, procedure or diagnosis, and trajectory — improving/stable/worsening]

Subjective

[Interval events since last note and patient-reported symptoms] (For inpatients: overnight events, pain control, GI function, voiding, respiratory symptoms, ambulation, wound/drain concerns. For outpatients: symptoms since discharge and functional recovery. State if no notable interval events occurred.)

Objective

Vitals: [Tmax, current temp, HR, BP, RR, SpO2 with oxygen delivery as relevant] (State "No vitals available" for telehealth or outpatient visits without vitals.)

I/O (24h): [Intake, output, net balance with breakdown if clinically relevant] (Inpatient only; omit entirely for outpatient visits.)

Lines/Drains/Devices: [Device type, location, output amount/character, site status, removal candidacy for each] (Omit entirely if no devices present.)

Exam: [Focused exam emphasizing surgical site: general appearance, cardiopulmonary status, abdomen, incision/wound assessment, ostomy if present, extremities for edema/DVT concern] (Document only what was assessed; state reason if exam limited.)

Data: [Pertinent labs with trends and key imaging/pathology relevant to today's decisions] (State "No new labs" or "No new imaging" when applicable.)

Assessment

[Brief synthesis: patient anchor, POD/HD and procedure or diagnosis, major interval events, current stability]

Problem List:

• [Problem — improving/stable/worsening with brief supporting data] (List active problems by acuity; omit resolved issues.)

Plan

(Organize by problem, matching the Assessment list.)

• [Problem]: [Specific actions: monitoring, diagnostics, therapeutic changes, consults, contingency plans] (Address perioperative elements within relevant problems: diet advancement, activity, DVT prophylaxis, antibiotics, drain/line management, wound care.)

Disposition: [Discharge target date, barriers, home services/equipment, follow-up] (Inpatient only.)

Outpatient Instructions: [Activity restrictions with duration, wound care, medication changes, return precautions, follow-up timing] (Outpatient only.)