Trauma Post-Op Check Note

Date/Time of Evaluation: [Date and time of bedside reassessment]

Location: [PACU / ICU / stepdown / floor]

Post-Op Day / Hours Post-Op: [POD# and/or hours since procedure]

Procedure(s): [Brief procedure label; details per operative note]

Operative Snapshot

[Key intraoperative events impacting immediate post-op care: major hemorrhage, contamination, intra-op hypotension, difficult airway, unexpected findings. Include resuscitation summary if significant with EBL and products given. Note airway status at case end and devices placed with type/location.] (If details not yet reviewed: "Per op note/anesthesia record—details pending.")

Subjective

(Include only if patient can participate; otherwise state: "Unable to obtain subjective history due to [reason]; comfort assessed via objective scale.")

[Patient status: awake and conversant / intubated and sedated / agitated / delirious]. [Key symptoms if obtainable: pain location/severity/response to intervention, dyspnea, nausea/vomiting, new neurologic symptoms—each with timing]

Objective

(Time-stamp all values. Indicate data source when from chart: "Per anesthesia record" or "Per flowsheet." Avoid "stable" without objective qualifiers.)

Vitals/Hemodynamics: [Time-stamped vitals with trend since arrival] [Vasoactive supports with doses if applicable] [Perfusion indicators: UOP in mL/hr over interval, lactate if available, active transfusion status]

Airway/Vent: [If intubated: ETT, vent mode/settings (RR, TV/pressure, PEEP, FiO2), SpO2, ABG summary if obtained] [If extubated: O2 delivery and flow, SpO2, respiratory effort]

Lines/Drains/Outputs: [Vascular access type and sites] [Drains/tubes: type, location, output amount and character over defined interval, device status] [Foley output in mL/hr] (If outputs pending: "Output pending measurement; will update by [time].")

Exam: [Focused to injuries/procedure—general appearance, neuro (alertness, pupils, motor/sensation in at-risk limbs), CV (pulses, perfusion), respiratory (breath sounds, chest wall), abdomen (distention, tenderness if assessable), compartments if at risk] (State what cannot be assessed and why.)

Wounds/Dressings: [Incision/dressing status: CDI vs saturation quantified] [Drain sites: secure, skin condition] [Open abdomen/packing/wound vac integrity if present] [Active bleeding: present/absent with location and amount]

Labs/Imaging: [Key labs with times: Hgb, lactate, coags as relevant] [Post-op CXR findings if obtained: ETT/line position, pneumothorax] [Pending studies with expected timing] (If critical data unavailable, document why and plan to obtain.)

Assessment

[Brief synthesis in 2–4 sentences: hemodynamic status and supports; presence/absence of ongoing bleeding; respiratory status; any concern for neurologic decline, compartment syndrome, or sepsis risk. If unstable, state working diagnosis and response underway.]

Plan

(Problem-based; include only domains relevant to this patient. Each item: action + timing/trigger for reassessment or escalation.)

• Hemodynamics/Bleeding: [MAP/UOP goals, transfusion thresholds, lab recheck timing, escalation triggers]
• Respiratory: [Vent wean plan or O2 target, ABG/CXR timing, pulmonary hygiene]
• Pain/Sedation: [Analgesia regimen, sedation target if vented, reassessment timing]
• Antibiotics: [Indication, agent, duration/stop criteria] (If not indicated, state explicitly with reassessment timing.)
• VTE Prophylaxis: [SCDs status, chemical prophylaxis started/held with rationale, re-evaluation timing]
• Fluids/Renal: [IVF plan, UOP goal, electrolyte repletion]
• Nutrition/GI: [Diet status, NG management, stress ulcer prophylaxis if indicated]
• Activity: [Bedrest vs mobilize, weight-bearing, precautions]
• Wounds/Drains: [Dressing plan, drain management, monitoring triggers]
• Disposition: [Level of care, vitals/neuro check frequency, next reassessment timing]