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.

Subjective

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).

• Pain: Is the patient having pain? How is the pain controlled? Normally a patient can't go home with an IV, so they have to be taking oral pain meds before they can go home.
• Drink: Is the patient eating and drinking a normal "average" diet? Do they feel nauseated, have the vomited? Sometimes it takes time for the GI tract to wake up, especially if the patient had abdominal surgery and there was manipulation of the intestines. Hopefully the patient's diet is advanced every day from clear liquids to full liquids to full diet. Multiple episodes of vomiting may require a nasogastric tube, one of the main barriers to discharge.
• Pee: Is the patient urinating on their own? Patient who may have urinary retention might end up coming back to the hospital within a day of discharge, so it is best to keep them and drain with a catheter if needed. Incontinence is the opposite issue, this could be due to medications or the patient's baseline function.
• Poop: Has the patient had a bowel movement? If not, have they passed gas? Flatulence indicates the GI tract is moving in the correct direction, and many surgical teams will not feed the patient unless they pass a good amount of gas. Bowel movements are even better, but might not be required before discharge on some services. Make sure the patient is taking stool softeners, as pain meds can cause constipation.
• Walk: Is the patient able to walk independently? If not, make sure the patient is making progress towards independent function. Stubborn patients who sit in bed make slower progress and are at higher risk for complications. Getting patients out of bed and moving is important for good surgical outcomes, as well as patient physical and mental wellbeing.

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):

• Pain - post-surgical, nerve damage
• Fever - infection, pulmonary embolism, aspiration
• Headache - med reaction, infection, aggravation with getting woken up every hour
• Chest pain - heart attack
• Shortness of breath - pulmonary embolism or edema
• Abdominal pain - ileus/obstruction
• Leg pain/weakness - deep vein thrombosis

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.

Objective

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.

• General Appearance: Hopefully you've seen this patient before. Does the patient look better or worse than yesterday, and it what way? This can help determine if the patient is making progress or if something is going wrong.
• HEENT: Not usually included in gen surg notes, but depends on the patient. Maybe they have an NG tube in place, or facial fractures. If there are relevant findings, mention them.
• Lungs: Make sure the patient has normal breath sounds, or improving atelectasis/edema. Changes in exam can be edema, atelectasis, or pneumonia.
• Heart: Normally, patients don't suddenly develop murmurs, but they might develop A-fib or other arrhythmias. However, if your patient just had heart surgery, definitely take a listen.
• Abdomen: Listening for bowel sounds is super non-specific. It's easier to just ask the patient if they vomited or have been constipated. Make sure you push on the abdomen to assess for tenderness or new masses or other changes in findings. Hopefully patients with ileus should have decreased tenderness as time progresses.
• Incision: If your patient is on the surgical service, chances are they have an incision somewhere. The incision should be clean, dry, and intact. If not, take note of what it looks like. Is it covered with some sort of dressing?
• Drains: Patients may have one or more drains. Note how much fluid is in the drains, their locations, and the color of the fluid. Hopefully the color should become less bloody with time, and decrease in amount.
• Extremities: It's pretty easy to check radial pulses, but not always necessary. It's a good habit to check patients' calves for signs of DVTs, but not really specific. Also make sure they can wiggle their toes, AKA a quick gross neuro exam.
• Neuro: If a patient had extremity surgery, assess for sensation and strength. Make sure the patient isn't having neuropathy from OR positioning. Talking to a patient should give you a good sense of whether they are oriented, but it can't hurt to double check. Checking pupils is also a good quick neuro test.

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.

Assessment

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.

Plan

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.

• Neuro: Mention any issues with patients mental status here.
• CV: Mention need for EKG monitoring, echo, or anything else.
• Pulm: Make sure the patient has an incentive spirometer!
• GI: Mention the patient's diet.
• Renal: Usually the IV fluid regimen is listed here.
• Heme: Does the patient need a transfusion?
• ID: Does the patient need antibiotics?
• Endo: Mention patient's glycemic regimen, if they have one.
• PPX: Mention if the patient has any ulcer (PPI) or embolic (heparin) prophylaxis.
• Disp: Once the patient is well, will they go home, to a nursing home, or somewhere else?
• Code: Is the patient DNR/DNI, or full code?