[comment memo_color="pink" memo="POST-OP ROUNDING NOTE"]

[comment memo_color="blue" memo="SUBJECTIVE"]
[text name="name" default=""] is a [text name="age" default=""] year-old [select name="sex" value="|male|female"] with a past medical history of [text name="hx" default=""] and is currently post-op day [select name="pod" value="|1|2|3|4|5|6|7|8|9|10"] following a [text name="proc" default=""]. This morning, the patient reports feeling "[text name="variable_1" default=""]". Last pain score was [select name="painscore" value="|1|2|3|4|5|6|7|8|9|10"]/10 obtained at [text name="paintime" default=""] currently being managed with [text name="paindrug" default=""]

[checkbox name="No_adverse_events_overnight" memo="No adverse events overnight" value=""][checkbox name="Adverse_events_overnight" memo="Adverse events overnight" value=""]
[checkbox name="Afebrile" memo="Afebrile (N = 36.4-37.2 °C" value=""][checkbox name="Febrile" memo="Febrile (N = 36.4-37.2 °C" value=""]
[checkbox name="No_flatus" memo="No flatus" value=""][checkbox name="Flatus" memo="Flatus" value=""]
[checkbox name="No_BMs" memo="No bowel movements" value=""][checkbox name="BMs" memo="Bowel movements" value=""]
[checkbox name="Not_ambulating" memo="Not ambulating" value=""][checkbox name="Ambulating" memo="Ambulating" value=""]
[conditional field="No_adverse_events_overnight" condition="(No_adverse_events_overnight).is('')"]No adverse events were reported overnight.[/conditional][conditional field="Adverse_events_overnight" condition="(Adverse_events_overnight).is('')"]Overnight, the patient [textarea memo="" rows="2"].[/conditional][conditional field="Afebrile" condition="(Afebrile).is('')"]Patient is currently afebrile.  [/conditional][conditional field="Febrile" condition="(Febrile).is('')"]Patient is currently febrile with a temperature of [text name="temp_febrile" default=""]. [/conditional][conditional field="No_flatus" condition="(No_flatus).is('')"]Patient has had no flatus and [/conditional][conditional field="Flatus" condition="(Flatus).is('')"]Patient has had flatus and [/conditional][conditional field="No_BMs" condition="(No_BMs).is('')"]has had no bowel movements. [/conditional][conditional field="BMs" condition="(BMs).is('')"]has had [text name="number_BMs" default=""] [select name="character_BMs" value="|loose|formed"] stools.[/conditional] [conditional field="Not_ambulating" condition="(Not_ambulating).is('')"]As of yesterday afternoon, patient has not ambulated. [/conditional][conditional field="Ambulating" condition="(Ambulating).is('')"]As of yesterday afternoon, patient has ambulated [select name="times_ambulating" value="|1|2|3|4|5|6|7|8|9|10"] times.[/conditional] 

[comment memo_color="blue" memo="LABS"]
[checkbox name="VS_WNL" memo="VS WNL" value=""][checkbox name="VS_Abnormal" memo="VS Abnormal" value=""]
[checkbox name="CMP_WNL" memo="CMP WNL" value=""][checkbox name="CMP_Abnormal" memo="CMP Abnormal" value=""]
[checkbox name="CBC_WNL" memo="CBC WNL" value=""][checkbox name="CBC_Abnormal" memo="CBC Abnormal" value=""]
[conditional field="VS_WNL" condition="(VS_WNL).is('')"]Vital signs have been trending WNL. [/conditional][conditional field="VS_Abnormal" condition="(VS_Abnormal).is('')"]Vital signs have been trending normally except for [text name="abn_VS" default=""], which is trending [text name="abn_VS_trend" default=""]. [/conditional][conditional field="CMP_WNL" condition="(CMP_WNL).is('')"]CMP has been trending WNL. [/conditional][conditional field="CMP_Abnormal" condition="(CMP_Abnormal).is('')"]CMP shows abnormalities in [textarea memo="" rows="3"]. [/conditional][conditional field="CBC_WNL" condition="(CBC_WNL).is('')"]CBC has been trending WNL. [/conditional][conditional field="CBC_Abnormal" condition="(CBC_Abnormal).is('')"]CBC shows abnormalities in [textarea memo="" rows="3"]. [/conditional]
Intake = [text name="ins" default=""]
Output = [text name="out" default=""]
Urine = [text name="urine" default=""]
Weight = [text name="weight" default=""]
Net I/O = [text name="net" default=""]
Patient urine per hour = [calc value="score1=((urine)+(weight))/24"] mg/kg/hr (N = 0.5-1.5 mg/kg/hr)

[comment memo_color="blue" memo="A/P"]
[checkbox name="Diet_POD1" memo="Diet POD1" value=""][checkbox name="Diet_POD2" memo="Diet POD2" value=""][checkbox name="Diet_POD3" memo="Diet POD3" value=""][checkbox name="Diet_POD4" memo="Diet POD4" value=""][checkbox name="Diet_POD5" memo="Diet POD5" value=""]
[checkbox name="No_tubes" memo="JG tube not present" value=""][checkbox name="Tubes" memo="JG tube present" value=""]

Plan is to [conditional field="Diet_POD1" condition="(Diet_POD1).is('')"]continue clear liquid diet for rest of POD1. [/conditional][conditional field="Diet_POD2" condition="(Diet_POD2).is('')"]progress to full liquid diet for rest of POD2. [/conditional][conditional field="Diet_POD3" condition="(Diet_POD3).is('')"]progress to regular diet for rest of POD3 as tolerated.  [/conditional][conditional field="Diet_POD4" condition="(Diet_POD4).is('')"]continue regular diet for rest of POD4 as tolerated. [/conditional][conditional field="Diet_POD5" condition="(Diet_POD5).is('')"]continue regular diet for rest of POD5 as tolerated. [/conditional] 
Continue analgesic and thromboprophylactic  meds as needed. 
Monitor glucose and administer insulin [select name="insulin" value="|lispro|aspart|glulisine|(regular)|glargine|detemir"] as needed. 
[conditional field="Tubes" condition="(Tubes).is('')"]Monitor and strip JG tubes 3 times per day. [/conditional]
[textarea name="additional_ap" default=""]

is a year-old with a past medical history of and is currently post-op day following a . This morning, the patient reports feeling "". Last pain score was /10 obtained at currently being managed with

No adverse events overnight Adverse events overnight
Afebrile (N = 36.4-37.2 °C Febrile (N = 36.4-37.2 °C
No flatus Flatus
No bowel movements Bowel movements
Not ambulating Ambulating

VS WNL VS Abnormal
CMP WNL CMP Abnormal
CBC WNL CBC Abnormal

Intake =
Output =
Urine =
Weight =
Net I/O =
Patient urine per hour = score1=((urine)+(weight))/24 mg/kg/hr (N = 0.5-1.5 mg/kg/hr)

Diet POD1 Diet POD2 Diet POD3 Diet POD4 Diet POD5
JG tube not present JG tube present

Plan is to
Continue analgesic and thromboprophylactic meds as needed.
Monitor glucose and administer insulin as needed.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.59, 76 form elements, 73 boilerplate words, 16 text boxes, 4 text areas, 23 checkboxes, 6 drop downs, 4 comments, 1 calculations, 22 conditionals, 49 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: