General Surgery Patient Follow-up Checklist
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Vital signs |
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Input and output (including urine, NGT, drains,
chest tubes) + description of output (eg, clear,
cloudy, bloody, or other color and appearance)
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IV fluids: type and rate |
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Antibiotics: duration, end date |
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Anticoagulation if not contraindicated |
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GI prophylaxis (eg, H2 blockers) |
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Pain medication |
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Nutrition |
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Laboratory test results |
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Imaging test results |
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Discharge planning |
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Preoperative Note
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Date and time |
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Preoperative diagnosis |
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Type of the procedure planned |
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Indication for surgery |
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Surgeon |
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Anesthesia |
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Laboratory workup (eg, CBC, metabolic profile, PTT, PT, LFT) |
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ECG and chest radiograph |
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Medications (eg, insulin, steroids) |
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Allergies |
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Antibiotics and VTE prophylaxis |
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NPO order and IVF |
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Operative Note
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Date and time of the procedure |
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Preoperative diagnosis |
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Postoperative diagnosis |
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Surgical procedure |
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Attending surgeon & assistants |
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Operative findings |
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Estimated blood loss |
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Drains, tubes, specimens |
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Type of anesthesia |
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Urine output and IVF received
during the procedure |
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Complications |
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Transfer location |
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Postoperative Note
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Date and time |
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Type of procedure |
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Subjective: patients concerns/ complains/pain score
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Objective: vitals, urine output, drain output |
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Physical exam: surgical dressing, drains, and tubes |
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Laboratory data
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Assessment of the condition |
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Plan |
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