Post-Operative Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Post-Operative Note

Date/Time:

Patient Identification: [Enter patient name, medical record number, age, sex]

Surgeon/Assistants: [Enter attending surgeon and any assistants]

Preoperative Diagnosis: [Enter preoperative diagnosis]
Postoperative Diagnosis: [Enter postoperative diagnosis]

Procedure Performed: [Enter name and description of procedure(s) performed]

Indications: [Briefly state why surgery was indicated]

Anesthesia: [Type of anesthesia and relevant anesthetic details]

Estimated Blood Loss: [Enter EBL in mL]

Fluids and Blood Products: [Detail intraoperative IV fluids, crystalloids, colloids, blood products]

Specimens Removed:
(hyphenated list)
- [Specimen 1: description]
- [Specimen 2: description]

Drains/Tubes:
(hyphenated list)
- [Type/location of drain or tube; output if applicable]
- [Next planned change or removal date]

Dressings:[Describe current dressing(s) over incision site(s)]

Postoperative Vital Signs:
(hyphenated list)
- Heart rate: [#] bpm
- Blood pressure: [#]/[#] mmHg
- Respiratory rate: [#] /min
- Temperature: [#] °C/°F
- O₂ saturation: [%] on [room air or device]

Intake and Output:
(hyphenated list)
- Intake: [type and volume]
- Output: [type and volume]

Plan:
(hyphenated list)
- Pain management: [e.g., Continue IV opioids, transition to PO as tolerated]
- Antibiotics: [e.g., Continue cefazolin IV until post-op day 2]
- Diet: [e.g., NPO → clear liquids → regular as tolerated]
- Activity: [e.g., Ambulate with assistance 3×/day]
- IV fluids: [e.g., D5½NS at 75 mL/hr]
- Labs/Imaging: [e.g., CBC and BMP morning of post-op day 1]
- Wound care: [e.g., Change dressing daily; monitor for signs of infection]
- Discharge planning: [e.g., Anticipated post-op day 3; physical therapy eval]

Disposition:
- [Enter current postoperative condition, level of care (e.g., ICU vs. floor), and follow-up plan]