Gyn/Gyn Onc Student Progress Note
Date:
Time:
POD#1 (HD#1) Procedure: s/p____ [TAH/BSO, Staging, D&C, LSC Salpingectomy, Xlap, etc. for [PMB, pelvic mass, ectopic preg, SBO, etc.]
S: +/- c/o, N/V, SOB, CP, F/C. Tolerating reg/fulls/NPO. Pain well controlled, ambulating, BM/flatus (if post-op), urinating, any events overnight. VB and number of pads if applicable.
O: Tm: (& time)/Tc: BP: current (range) P: R: O2 sat: Ins/Outs:
EX:1500NS/1300uop over 12 hrs, 200NG
Gen: AAOx3, comfortable
CV:
Lungs:
Abdomen: soft, NT(ApprT)ND, +BS, (if ttp: guarding, rebound)
Inc: Remove bandage POD1!! c/d/i with: staples, etc
No erythema, exudate, induration, +drain in place
GU: vag pack in place (don’t need to do GU exam, just know if vag
pack present. Resident will remove/instruct.)
Ext: c/c/e (pitting), Nontender, no cord, SCD’s present
Labs: PCV pre-op→ opst-op, blood sugars, any new labs not previously
documented
Imaging: any new studies not previously documented.
Meds: Abx and day # (ex: Day #2 A/G/CO Include IVF’s and rate)
A/P: ___yo__F HD#1 for_____ or POD#1 s/p____for____. VB improved, abd pain improved, etc. or Doing well, stable
If not post-op, address active issues: for example
- VB - s/p IV estrogen and methergine
- Anemia – s/p 2 units. PCV 21->27 HD stable.
Address surgical issues:
- RPOC – d/c foley, plan for voiding trial if need, advance diet, HLIV, vag pack/ bandage removed, ambulate, change to PO pain meds, wean oxygen if not on at home.
Always address:
- PPx: SCD/TED, Lovenox, PPI, Abx
- FEN – Diet, are we advancing or making NPO
Fluids – decreasing, increasing
UOP – adequate? Foley in? D/C’ing foley?
BRIEFLY address other medical problems if no issue
- HTN, Asthma, depression – start home meds if appr.
Which home meds are they on?
SIGN YOUR NOTE!!
Daily Thoughts:
Can any IV drugs be made PO?
How can I get this pt out of bed today?
Can the foley, lines, tube come out?
Does pt have bowel fxn and can diet be advanced?
Is the social worker aware of the discharge plan?
Gyn/Gyn Onc Student Progress Note
Date:
Time:
POD#1 (HD#1) Procedure: s/p____ [TAH/BSO, Staging, D&C, LSC Salpingectomy, Xlap, etc. for [PMB, pelvic mass, ectopic preg, SBO, etc.]
S: +/- c/o, N/V, SOB, CP, F/C. Tolerating reg/fulls/NPO. Pain well controlled, ambulating, BM/flatus (if post-op), urinating, any events overnight. VB and number of pads if applicable.
O: Tm: (& time)/Tc: BP: current (range) P: R: O2 sat: Ins/Outs:
EX:1500NS/1300uop over 12 hrs, 200NG
Gen: AAOx3, comfortable
CV:
Lungs:
Abdomen: soft, NT(ApprT)ND, +BS, (if ttp: guarding, rebound)
Inc: Remove bandage POD1!! c/d/i with: staples, etc
No erythema, exudate, induration, +drain in place
GU: vag pack in place (don’t need to do GU exam, just know if vag
pack present. Resident will remove/instruct.)
Ext: c/c/e (pitting), Nontender, no cord, SCD’s present
Labs: PCV pre-op→ opst-op, blood sugars, any new labs not previously
documented
Imaging: any new studies not previously documented.
Meds: Abx and day # (ex: Day #2 A/G/CO Include IVF’s and rate)
A/P: ___yo__F HD#1 for_____ or POD#1 s/p____for____. VB improved, abd pain improved, etc. or Doing well, stable
If not post-op, address active issues: for example
- VB - s/p IV estrogen and methergine
- Anemia – s/p 2 units. PCV 21->27 HD stable.
Address surgical issues:
- RPOC – d/c foley, plan for voiding trial if need, advance diet, HLIV, vag pack/ bandage removed, ambulate, change to PO pain meds, wean oxygen if not on at home.
Always address:
- PPx: SCD/TED, Lovenox, PPI, Abx
- FEN – Diet, are we advancing or making NPO
Fluids – decreasing, increasing
UOP – adequate? Foley in? D/C’ing foley?
BRIEFLY address other medical problems if no issue
- HTN, Asthma, depression – start home meds if appr.
Which home meds are they on?
SIGN YOUR NOTE!!
Daily Thoughts:
Can any IV drugs be made PO?
How can I get this pt out of bed today?
Can the foley, lines, tube come out?
Does pt have bowel fxn and can diet be advanced?
Is the social worker aware of the discharge plan?
Gyn/Gyn Onc Student Presentation Template
Ms. ______is a _____ yo female who is now hospital day number/post-op day number ___s/p______for ______. Her post-operative/hospital course has been complicated by ______(ex. Ileus, pneumonia, inability to void.)
This morning, she is without complaints/complains of ______(ex. Post-op abdominal pain, nausea, etc.) She is still NPO or She is/is not tolerating a _____ diet. She is/is not ambulating. She does/does not have evidence of bowel function (i.e. flatus, bowel movement).
Over the last 24 hours, her Tmax was _____. She has now been afebrile since _____ (If ever febrile). Other vital signs are stable, and she has had adequate urine output with _____ cc over 24hrs. Her physical exam is within normal limits/is unchanged. (If post-op, be sure to comment on abdominal exam and incision, keeping in mind that some abdominal tenderness is normal post-op. Also comment on other pertinent findings, such as lung exam with pneumonia/pulm, edema, or extremity exam if working up for DVT.
Her hematocrit is ____, from ____ pre-op (Also comment on other pertinent labs, such as WBC if febrile or admitted for neutropenia, platelets if admitted with thrombocytopenia, creatinine if admitted to evaluate kidney status).
The plan for her today on POD1 is to d/c Foley (+/- voiding trial), change to p.o. pain meds, HLIV, advance diet, ambulate. (Other things may include starting home meds, addition of antibiotics, imaging or other procedures, etc.)
Try to organize presentation plan by system or problem if many issues or complex course.
Gyn/Gyn Onc Student Presentation Template
Ms. ______is a _____ yo female who is now hospital day number/post-op day number ___s/p______for ______. Her post-operative/hospital course has been complicated by ______(ex. Ileus, pneumonia, inability to void.)
This morning, she is without complaints/complains of ______(ex. Post-op abdominal pain, nausea, etc.) She is still NPO or She is/is not tolerating a _____ diet. She is/is not ambulating. She does/does not have evidence of bowel function (i.e. flatus, bowel movement).
Over the last 24 hours, her Tmax was _____. She has now been afebrile since _____ (If ever febrile). Other vital signs are stable, and she has had adequate urine output with _____ cc over 24hrs. Her physical exam is within normal limits/is unchanged. (If post-op, be sure to comment on abdominal exam and incision, keeping in mind that some abdominal tenderness is normal post-op. Also comment on other pertinent findings, such as lung exam with pneumonia/pulm, edema, or extremity exam if working up for DVT.
Her hematocrit is ____, from ____ pre-op (Also comment on other pertinent labs, such as WBC if febrile or admitted for neutropenia, platelets if admitted with thrombocytopenia, creatinine if admitted to evaluate kidney status).
The plan for her today on POD1 is to d/c Foley (+/- voiding trial), change to p.o. pain meds, HLIV, advance diet, ambulate. (Other things may include starting home meds, addition of antibiotics, imaging or other procedures, etc.)
Try to organize presentation plan by system or problem if many issues or complex course.