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