**POST-OP ROUNDING NOTE**
[comment memo_color="pink" memo="POST-OP ROUNDING NOTE"] [comment memo_color="blue" memo="SUBJECTIVE"] ---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=""] ---OVERNIGHT--- [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=""] ---LABS--- [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=""] ---A/P--- 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=""]
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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
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