Surgery Patient Name

MR Number
Op Note:
DOB • Look in your pocket. There should be a Maxwell’s in
there. Follow the format given to you.
Date General Surgery Daily/Progress Note—MS III  
Time S: 24 hour events… the nurses’ observations may be helpful. Pt. subjective Things to Know:
assessment of N/V/F/C, pain, wound, SOB, bowel activity, all per the patient. • Surgeons are to the point—they want no more and no less
info than is needed to take care of the Pt.
O: Vitals: Tmax / Tcurrent / bp / hr / resp / O2 sats/accucheck • PATs are pre-op physical exams performed in the
Vent settings: Surgical Admitting Center: be thorough and quick.
• Your job will often consist only of retracting and cutting
I/O: last 8hr- ‘in” (PO, IV)/ “outs” (urine, stool)
sutures. Become adept with steady hands.
previous 24hr- ‘in” (PO, IV)/ “outs” (urine, stool)
• Practice your knots so you can be a star when you get to
Labs: suture something.
• Always carry an energy bar or food in your lab coat
Meds:
pocket (a different pocket from your hemoccult supplies).
Exam: GEN: • Pee BEFORE going to the OR. It is bad form to scrub
HEENT: out routinely for bathroom breaks.
CV: • It is always better to ask before touching/doing anything
PULM: if you are not sure!
• Divide up the cases the day before they are scheduled.
ABD: You should know about the case and the patient before
EXT: you get to the OR.
NEURO: • Always be in the OR waiting and ready when the
WOUND: attending arrives.
• Take advantage of procedure opportunities!
LINES: • No matter how much you are scolded and how tired you
A/P: __ y/o male/female with PMHx of ___ now with ______ (name the problem) s/p may be, remain a human being. That way you will still
(status-post name the type of surgery performed) _____, post-op day ___ (the day of have friends after surgery.
the operation is post-op day 0).
1.       CV
2.       HEME •List by problem for floor patients.
Books:
3.       PULM •List systems for ICU/MICU patients. • Surgery Recall (for answers to everyday pimp questions) or
4.       GI
Advanced Surgery Recall (for aspiring surgeons)
5.       RENAL •Be concise and direct. Do not say
• Surgical Attending Rounds (helpful when studying for oral
6.       WOUND “consider” or “suggest”
7.       ID exams)
•List each problem and your plan to • Principles of Surgery, Greenfield (to look up specifics)
8.       NEURO/PSYCH
9.       FEN (fluids/electrolytes/nutrition) “fix” it.
10. Disposition