***POST-OP F/U***

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posted 2023-08-05, updated 2023-08-08
Gastroenterology & Hepatology
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Room: [text name="room" default=""]

-----ONE-LINER-----
Name: [text name="name" default=""]
Age: [text name="age" default=""]
Sex: [select name="sex" value="Male|Female"]
PMHx: [text name="pmhx" default=""]
POD: [text name="pod" default=""]
Procedure: [text name="proc" default=""]

-----SUBJECTIVE-----
Patient reports feeling "[text name="" default=""]"
Adverse events: [select name="aeo" value="NAEON|AEO"][conditional field="aeo" condition="(aeo).is('AEO')"]. [textarea memo="" rows="2"][/conditional].
Fever: [select name="fever" value="Afebrile|Febrile"][conditional field="fever" condition="(fever).is('Febrile')"] | [text name="variable_1" default=""][/conditional] | (N = 36.4-37.2 °C)
Flatus: [select name="flatus" value="Yes|No"]
Bowel movements: [select name="BMs" value="Yes|No"] [conditional field="BMs" condition="(BMs).is('Yes')"] | [text name="bm_freq" default=""][/conditional]
Ambulation: [select name="ambulating" value="Not ambulating|Ambulating"] [conditional field="ambulating" condition="(ambulating).is('Ambulating')"] | [select name="number_amb" value="1|2|3|4|5|6|7|8|9|10|Multiple"] times[/conditional]
ROS: [checkbox name="ros" value="Nausea|Vomiting|Dysphagia|Dyspepsia|Loss of appetite|Tenesmus"]

-----PHYSICAL-----
[textarea name="pe" rows=3 default=""]

-----VITALS-----
[select name="vitals" value="Trending WNL|Abnormal"]
BP: [text name="bp" default=""] mmHg; HR: [text name="hr" default=""] bpm; RR: [text name="rr" default=""] breaths/min; Temp: [text name="temp" default=""]°C; SaO2: [text name="sao2" default=""]% 
[textarea name="vitalnotes" rows=3 default=""]

-----LABS-----
Na: [text name="na" default=""] (N = 136-148 mmol/L) [checkbox name="na_abn" value="**ABNORNAL**"] [conditional field="na_abn" condition="(na_abn).is('**ABNORNAL**')"]compared to [text name="na_abn_2" default=""] yesterday.[/conditional]
K: [text name="k" default=""] (N = 3.5-5.2 mmol/L) [checkbox name="k_abn" value="**ABNORNAL**"] [conditional field="k_abn" condition="(k_abn).is('**ABNORNAL**')"]compared to [text name="k_abn_2" default=""] yesterday.[/conditional]
Cl: [text name="cl" default=""] (N = 100-110 mmol/L) [checkbox name="cl_abn" value="**ABNORNAL**"] [conditional field="cl_abn" condition="(cl_abn).is('**ABNORNAL**')"]compared to [text name="cl_abn_2" default=""] yesterday.[/conditional]
HCO3: [text name="hco3" default=""] (N = 21-32 mmol/L) [checkbox name="hco3_abn" value="**ABNORNAL**"] [conditional field="hco3_abn" condition="(hco3_abn).is('**ABNORNAL**')"]compared to [text name="hco3_abn_2" default=""] yesterday.[/conditional]
BUN: [text name="bun" default=""] (N = 5-23 mg/dL) [checkbox name="bun_abn" value="**ABNORNAL**"] [conditional field="bun_abn" condition="(bun_abn).is('**ABNORNAL**')"]compared to [text name="bun_abn_2" default=""] yesterday.[/conditional]
Cr: [text name="cr" default=""] (N = 0.6-1.0 mg/dL) [checkbox name="cr_abn" value="**ABNORNAL**"] [conditional field="cr_abn" condition="(cr_abn).is('**ABNORNAL**')"]compared to [text name="cr_abn_2" default=""] yesterday.[/conditional]
Glucose: [text name="gluc" default=""] (N = 65-99 mg/dL) [checkbox name="gluc_abn" value="**ABNORNAL**"] [conditional field="gluc_abn" condition="(gluc_abn).is('**ABNORNAL**')"]compared to [text name="gluc_abn_2" default=""] yesterday.[/conditional]

WBC: [text name="wbc" default=""] (N = 4.8-10.8 K/uL) [checkbox name="wbc_abn" value="**ABNORNAL**"] [conditional field="wbc_abn" condition="(wbc_abn).is('**ABNORNAL**')"]compared to [text name="wbc_abn_2" default=""] yesterday.[/conditional]
Hgb: [text name="hgb" default=""] (N = 12-16 g/dL) [checkbox name="hgb_abn" value="**ABNORNAL**"] [conditional field="hgb_abn" condition="(hgb_abn).is('**ABNORNAL**')"]compared to [text name="hgb_abn_2" default=""] yesterday.[/conditional]
Hct: [text name="hct" default=""]% (N = 37-47%) [checkbox name="hct_abn" value="**ABNORNAL**"] [conditional field="hct_abn" condition="(hct_abn).is('**ABNORNAL**')"]compared to [text name="hct_abn_2" default=""] yesterday.[/conditional]
Plt: [text name="plt" default=""] (N = 130-400 K/uL) [checkbox name="plt_abn" value="**ABNORNAL**"] [conditional field="plt_abn" condition="(plt_abn).is('**ABNORNAL**')"]compared to [text name="plt_abn_2" default=""] yesterday.[/conditional]

AST: [text name="ast" default=""] (N = 0-48 U/L) [checkbox name="ast_abn" value="**ABNORNAL**"] [conditional field="ast_abn" condition="(ast_abn).is('**ABNORNAL**')"]compared to [text name="ast_abn_2" default=""] yesterday.[/conditional]
ALT: [text name="alt" default=""] (N = 13-61 U/L) [checkbox name="alt_abn" value="**ABNORNAL**"] [conditional field="alt_abn" condition="(alt_abn).is('**ABNORNAL**')"]compared to [text name="alt_abn_2" default=""] yesterday.[/conditional]
TBili: [text name="tbili" default=""] (N = 0-1.0 mg/dL) [checkbox name="tbili_abn" value="**ABNORNAL**"] [conditional field="tbili_abn" condition="(tbili_abn).is('**ABNORNAL**')"]compared to [text name="tbili_abn_2" default=""] yesterday.[/conditional]
DBili: [text name="dbili" default=""] (N = 0-0.4 mg/dL) [checkbox name="dbili_abn" value="**ABNORNAL**"] [conditional field="dbili_abn" condition="(dbili_abn).is('**ABNORNAL**')"]compared to [text name="dbili_abn_2" default=""] yesterday.[/conditional]
APhos: [text name="aphos" default=""] (N = 45-136 U/L) [checkbox name="aphos_abn" value="**ABNORNAL**"] [conditional field="aphos_abn" condition="(aphos_abn).is('**ABNORNAL**')"]compared to [text name="aphos_abn_2" default=""] yesterday.[/conditional]

Ca: [text name="ca" default=""] (N = 8.4-10.6 mg/dL) [checkbox name="ca_abn" value="**ABNORNAL**"] [conditional field="ca_abn" condition="(ca_abn).is('**ABNORNAL**')"]compared to [text name="ca_abn_2" default=""] yesterday.[/conditional]
Mg: [text name="mg" default=""] (N = 1.4-2.4 mg/dL) [checkbox name="mg_abn" value="**ABNORNAL**"] [conditional field="mg_abn" condition="(mg_abn).is('**ABNORNAL**')"]compared to [text name="mg_abn_2" default=""] yesterday.[/conditional]
PO4: [text name="po4" default=""] (N = 2.5-4.6 mg/dL) [checkbox name="po4_abn" value="**ABNORNAL**"] [conditional field="po4_abn" condition="(po4_abn).is('**ABNORNAL**')"]compared to [text name="po4_abn_2" default=""] yesterday.[/conditional]

Other Labs:[text name="otherlabs" default=""]

-----I/O-----
Intake PO: [text name="intakepo" default=""] mL
Intake IV: [text name="intakeiv" default=""] mL
Output Urine: [text name="outputur" default=""] mL
Urine production = [text name="urprod" default=""] mL/kg/hr
Left drain output: [text name="outputldr" default=""]
Right drain output: [text name="outputrdr" default=""]
Total Intake: [text name="intaketot" default=""] mL
Total output: [text name="outputtot" default=""] mL
Net I/O: [text name="netio" default=""] mL

-----IMAGING-----
[textarea name="imaging" default=""]

-----A/P-----
Feeding: [text name="feeding" default=""]
Drains: [text name="drains" default=""]
Insulin: [text name="insulin" default=""]
Electrolytes: Replete K+ to 4.0, replete Ca2+ to 2.5, replete Mg2+ to 2.5
D/c: [text name="dc" default=""]
[textarea name="vitalnotes" rows=2 default=""]
Room:

-----ONE-LINER-----
Name:
Age:
Sex:
PMHx:
POD:
Procedure:

-----SUBJECTIVE-----
Patient reports feeling ""
Adverse events: .
Fever: | (N = 36.4-37.2 °C)
Flatus:
Bowel movements:
Ambulation:
ROS:

-----PHYSICAL-----


-----VITALS-----

BP: mmHg; HR: bpm; RR: breaths/min; Temp: °C; SaO2: %


-----LABS-----
Na: (N = 136-148 mmol/L)
K: (N = 3.5-5.2 mmol/L)
Cl: (N = 100-110 mmol/L)
HCO3: (N = 21-32 mmol/L)
BUN: (N = 5-23 mg/dL)
Cr: (N = 0.6-1.0 mg/dL)
Glucose: (N = 65-99 mg/dL)

WBC: (N = 4.8-10.8 K/uL)
Hgb: (N = 12-16 g/dL)
Hct: % (N = 37-47%)
Plt: (N = 130-400 K/uL)

AST: (N = 0-48 U/L)
ALT: (N = 13-61 U/L)
TBili: (N = 0-1.0 mg/dL)
DBili: (N = 0-0.4 mg/dL)
APhos: (N = 45-136 U/L)

Ca: (N = 8.4-10.6 mg/dL)
Mg: (N = 1.4-2.4 mg/dL)
PO4: (N = 2.5-4.6 mg/dL)

Other Labs:

-----I/O-----
Intake PO: mL
Intake IV: mL
Output Urine: mL
Urine production = mL/kg/hr
Left drain output:
Right drain output:
Total Intake: mL
Total output: mL
Net I/O: mL

-----IMAGING-----


-----A/P-----
Feeding:
Drains:
Insulin:
Electrolytes: Replete K+ to 4.0, replete Ca2+ to 2.5, replete Mg2+ to 2.5
D/c:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.28, 122 form elements, 181 boilerplate words, 66 text boxes, 5 text areas, 20 checkboxes, 8 drop downs, 23 conditionals, 104 total clicks
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