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Jim's Surgery Progress Note Template

This document appears to be a daily progress note for a patient in the hospital. It includes sections to document overnight events, vital signs, pain levels, output, labs, procedures, and a plan of care. The note format allows for documentation of this information for both day and night shifts to track the patient's condition and progress over time.

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kat
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337 views1 page

Jim's Surgery Progress Note Template

This document appears to be a daily progress note for a patient in the hospital. It includes sections to document overnight events, vital signs, pain levels, output, labs, procedures, and a plan of care. The note format allows for documentation of this information for both day and night shifts to track the patient's condition and progress over time.

Uploaded by

kat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Room: Patient: POD# s/p: Room: Patient: POD# s/p:

S: O/N events - S: O/N events -


CP/SOB- Pain- Flatus/Stool- Pt/Fam q’s- CP/SOB- Pain- Flatus/Stool- Pt/Fam q’s-
N/V- Ambulation- Urination- N/V- Ambulation- Urination-

O Imaging: O: Imaging:
T max
T max
T current
T current
HR A/P:
A/P: HR 1. Pain
RR
1. Pain RR
BP
BP
O2 sat 2. Drains
2. Drains O2 sat
Vent:
Vent:
Mode
Mode 3. Diet
Rate 3. Diet Rate
TV
TV 4. Ambulation
FiO2
4. Ambulation FiO2
Pressure/PEEP
Pressure/PEEP 5. Abx
pH ___ pCO2 ___
5. Abx pH ___ pCO2 ___
pO2 ___ HCO3___
ABG Sat ___ Lac ___ pO2 ___ HCO3___
ABG Sat ___ Lac ___ 6. Medical Issues
I/O _________/_______ 6. Medical Issues
I/O _________/_______
U (total) _____/_____/_____
U (total) _____/_____/_____
St (total) _____/_____/_____
St (total) _____/_____/_____
Other outs
Other outs

Ins (rate)
Ins (rate)
Labs
Labs Prophy (DVT/GI)
Chemstick ____ -- ____ Prophy (DVT/GI) DISPO
DISPO Chemstick ____ -- ____ CODE STATUS
CODE STATUS
General-
General- Card-
Card- Pulm-
Pulm- Abd-
Abd- Ext-
Ext- Wound-
Wound-
| |
| | >--------< ---------------------<
>--------< ---------------------< | |
| |

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