General Surgeon-Vorlage
General Surgery Morning Ward Round
Eine professionelle General Surgeon-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document your general surgery ward rounds? This General Surgery Morning Ward Round template is perfect for surgeons. It helps you efficiently record patient status, vitals, medications, and plans for the day. This template ensures all critical information is captured, from post-operative recovery to discharge plans. Use this template to streamline your documentation process and improve patient care. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving accuracy.
Vorlagenvorschau
**General Surgery Ward Round:**
Context of admission: The patient, a 67-year-old male, presented with acute cholecystitis and underwent an emergency laparoscopic cholecystectomy on 29 October 2024. This is day 3 post-operation.
Assessment of post-operative recovery: The patient is recovering well, with good pain control and minimal nausea. He is tolerating oral intake and ambulating independently.
**Current Status:**
Current patient status: The patient reports mild incisional pain, otherwise feeling well. Nursing staff report no concerns.
Significant events: No significant events since admission.
**Nutrition Status:**
- Fluids: 2000ml IV Hartmann's overnight, now PO.
- Oral intake: Tolerating a regular diet.
- Output: Urine output 1500, no stoma or drains.
- Total fluid balance: +500
**Mobility:**
- Ambulating independently.
**Today's Observations and Vitals:**
- BP 130/80
- HR 78
- SpO2 98% on room air
- Temp 37.1
**Pain Status:**
- Pain level 2/10, well controlled with PRN paracetamol 1g PO.
**Escalation Status:**
- Full.
**Symptoms:**
- Mild incisional pain.
**Current Medication:**
- Continue: Paracetamol 1g PO QDS, Ondansetron 4mg PRN, Clexane 40mg SC daily.
- Stopped: IVABx.
**Multidisciplinary Team Input:**
- Physiotherapy reviewed and advised on mobility exercises.
**Today's Ward Plan:**
- Continue regular diet.
- Encourage ambulation.
- Monitor pain and administer PRN analgesia.
- Review blood results.
**Discharge Plan:**
- Plan for discharge tomorrow if pain is controlled and tolerating diet.
- Provide patient with discharge medications and instructions.
**Follow-up Plan:**
- GP follow-up in 2 weeks.
**Jobs:**
- Arrange discharge summary.
- Review blood results.
**Patient and Doctor Conversation:**
- Discussed the patient's progress and discharge plan. The patient expressed satisfaction with his care and understanding of the plan. The patient's wife was present and also understood the plan.
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