How to Know Everything about Your Surgical Patient

Doctors on the medical side admit patients who are sick, diagnose, and treat. Surgeons, on the other hand, operate on relatively healthy patients, then discharge the patient. The goals of the progress note and rounds presentation are to determine what needs to be accomplished to send the patient home, and to identify complications that may delay the patient's discharge. The page will go through how to write a thorough yet concise note to answer these questions, as well as provide a framework for a presentation on rounds. Importantly, although the note may have a lot of information, it is best to summarize during rounds. Have any additional information on the patient in your notes, in case asked by a team member.


Again, there are two main questions that need to be answered. One, is the patient ready to be discharged home and will they be able to function outside the hospital? Two, are there any complications that need to be treated before the patient can go home?

Post-Surgical Progress: These are the questions I ask to know whether the patient is getting ready to go home. The majority of patients do not have the equipment or personnel available at the hospital, so figure out whether the patient can function in a normal setting. I like to break this into 5 main questions (PDPPW).

Post-Surgical Complications There's a couple different ways to think about complications, and asking the patient about them. The main complications tend to be bleeding, infection, or damage to nearby structures (all covered during informed consent). Complications may also be specific to the surgery, or general post-surgical issues. My go-to list (excluding what I've already asked above):
You may want to also include any issues mentioned in the patient chart from overnight. I try to chart check before entering the patient's room to save time discussing issues that have already been solved, or new issues that pop up overnight.


The objective section include your observations and labs/imaging. Personally, the first thing I do when I show up is get vitals, labs, and I/Os from the chart. This helps me determine if there are certain patients I am more worried about and should see first.

Vitals: Normally this can be found in the chart. I record the range and the most recent value. To look like a pro, look for trends in the abnormalities. If the patient had a fever, was it one isolated episode, or did it come with tachycardia and hypotension? Big difference.
Physical Exam: Obviously, your findings upon looking at the patient. Instead of doing a medicine physical, focus on important and relevant exam maneuvers and findings. You're going to want to change your exam based on the situation for each patient. I think the most important aspect to remember is looking for changes in your patient's exam from day to day. It's not necessary to listen for murmurs for 5 minutes every day. If the patient didn't have a murmur on day 1, they probably won't on day 7 either.

Medications: It's often a good idea to have a list of the patient's meds in the note, but not necessary to mention in a presentation. They're usually snuck in around here.
Input/Output: Pull this from the patient chart. I write "TI/PO/TO/Urine," which means Total Input, Oral Intake, Total Output, and Urine (duh). I don't usually record IV input, because that can be calculated easily from the numbers already listed. If the patient has drains, write down how much is coming out of each and where they're located. That way if ones putting out 5mL and 500mL, you know where to expect a fluid collection. Also a good place to note how many bowel movements the patient had. To look really good, write the previous 24 hour I/Os in parentheses on your sheet, so you can figure out whether the patient's urine output is improving, or whether they're drinking more like they said they would.
Labs: Almost all patients have a complete blood count (CBC) and basic metabolic panel (BMP) drawn every morning. For CBC, the usual format is "WBC, Hgb, Hct, Plt." You don't even have to explain what each number is, as long as you always list them in the same order. If a value is outside the normal range, try to record the previous day's value for comparison, or a trend since admssion/surgery. For BMP, it's usually presented as "Na+, K+, Cl-, CO2, BUN, Cr, Glu." Some patients may have extra electrolyte labs, presented as "Ca2+, Mg2+, Phos." If the patient has any other new labs, mention those too! Always check to see if labs that take a few days have come back yet.
Imaging: If imaging was performed, mention the impression. It's not necessary to go through every nuanced finding on the scan, unless it's super relevant.


It's time to show you know what you're doing, so bring your A-game (A for assessment). Quickly summarize the reason the patient is admitted to the service, AKA what surgery did they have and for what. Also summarize what's happened since they've been on the floor. I like to make a second paragraph going over any new updates from the past 24 hours. I often put this paragraph in bold. In a third paragraph, I like to discuss the reasons why the patient cannot be discharged today, AKA "barriers to discharge." This helps me sort out my thoughts and figure out what I (and the patient) need to do to get them home.


There's a couple different ways to organize your plan. One is to go by patient problems. Another is to go by organ system. I prefer organ system, but either one works. Often the plan is copied forward every day and can get awfully bloated. My personal strategy is to copy and paste the plan from yesterday. Then I update the plan with any changes or findings, and I put these in bold. Don't forget new things you want to order, or items to check up on later in the day or tomorrow. Next, I remove any non-relevant updates from previous days, especially if that issue has been completely resolved. I try to list each of the medications with the respective organ system, the dosage and timing; something I picked up from my medicine rotation.