Wound/Drain Check Note (Surgery)

Date/Time of Service: [Date and time]

Location/Setting: [clinic / inpatient / ED / telehealth]

Author & Service: [Name, role, service/team]

Primary Procedure & Date: [Procedure name and date]

Post-op Day: [POD number]

Reason for Visit: [Wound and/or drain check indication]

Subjective

[Interval history] (2–4 sentences: time since surgery or last check; symptom course [improved / stable / worsened]; functional impact.)

[Targeted symptom screening] (Document presence or absence of: fever/chills; changes in incisional pain; spreading redness; new or changed drainage; wound separation; bleeding.)

[Home wound care] (Dressing type; change frequency; who performs care; any difficulties; current antibiotics with agent/dose/duration if applicable.)

Drains (patient-reported): (Document each drain separately. Label outputs as estimated unless measurement log confirmed.)

• [Drain #1]: [Type and anatomic location]; [Output log: measured / patient-estimated / unavailable]; [Recent output trend and approximate 24h total]; [Character: serous / serosanguinous / sanguineous / cloudy / purulent]; [Problems: none / clogging / leakage / dislodgement / suction issues]. (If output unavailable, state explicitly and note plan to obtain.)

• [Drain #2]: (Repeat as above; add additional drains as needed.)

Objective

Vitals: [Temperature (°C/°F)] [Heart rate (bpm)] [Blood pressure (mmHg)] [Respiratory rate] [SpO2 %] (Required when infection concern exists; note if afebrile on antipyretics. Use placeholder if not obtained rather than omitting.)

General: [Appearance; distress level; toxicity]

Wound Assessment: [Site and laterality]; [Closure type or open]; [Dressing status on arrival]; [Edge approximation vs separation with gap measurement in cm if present]; [Periwound skin: erythema extent in cm, warmth, induration, tenderness]; [Drainage amount and character]; [Wound bed and measurements in cm if healing by secondary intention].

Drain Assessment: (Document each drain separately.)

• [Drain #1]: [Type and location]; [Site skin condition]; [Tubing patency]; [Suction function]; [Most recent 24h output in mL with trend]; [Character and any abrupt changes].

• [Drain #2]: (Repeat as above.)

Data: [Relevant labs]; [Culture results or pending]; [Imaging findings]. (For pending cultures, document callback plan: who reviews and how patient will be notified.)

Assessment

• Wound: [healing appropriately / delayed healing / concerning for SSI / seroma / hematoma / dehiscence]. (Cite supporting findings: erythema extent, drainage character/amount, separation measurements.)

• Drain status: [appropriate to continue / criteria met for removal / concern for malfunction]. (Reference output trends, character, suction function, site condition.)

• Infection consideration: (If suspected: [superficial incisional / deep incisional / organ-space]; [systemic signs present / absent]; key supporting or refuting findings.)

Plan

Wound Care: [Cleansing instructions]; [Dressing type and frequency]; [Who performs care]; [Activity restrictions]; [Staple/suture removal timing if applicable].

Drain Management: (Document each drain separately. Do not state removal criteria met unless supporting data recorded above.)

• [Drain #1]: [Continue / Remove]; [Removal criteria applied with supporting data: 24h output, character, site condition]; [Patient instructions: output measurement, suction maintenance, site care, when to call].

• [Drain #2]: (Repeat as above.)

Infection Management: (Include if applicable.) [Working diagnosis and depth]; [Source control plan]; [Culture plan with specimen source]; [Antibiotic agent(s), route, duration, rationale linked to severity and culture data].

Follow-up: [Interval and location]; [Who reviews pending results and patient notification method]; [Return precautions].

Procedures Performed

(Include only if procedure performed during visit.)

• Drain removal: [Indication with criteria]; [Consent]; [Drain identified]; [Technique]; [Complications or none]; [Dressing]; [Aftercare instructions].

• Wound culture: [Specimen source]; [Collection method]; [Timing relative to cleansing/antibiotics]; [Lab destination].

• I&D or debridement: [Indication]; [Anesthesia]; [Findings]; [Irrigation/packing]; [Complications].