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Surgery
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Surgical Procedure
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Date of Surgery
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Name of Surgical Facility
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New Field
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Subjective Notes
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Objective
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Objective Notes
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Pain Score
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What factors decrease pain?
• • •
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Complaints of
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Patient Denies
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Using Assistive Device?
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Assistive Device in Use
• • •
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Has Patient Had Bowel Movement?
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Did they need assistance?
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Medication used to assist in BM
• • •
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Photo
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New Field
• • •
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Photo
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Clean/Dry/Intact?
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Photo
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Erythema
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Photo
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Swelling at incision site?
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Blood Pressure
/
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Temperature
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Pulse
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Current Pain Medication
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Assessment
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How is Patient doing?
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Assessment Notes
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Plan
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