General Surgery Morning Ward Round

**General Surgery Ward Round:** [context of admission including whether it was an elective or emergency admission, details of the surgery performed, and the day post-operation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph of full sentences using acronyms where possible.) [assessment of post-operative recovery since admission] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) **Current Status:** [current patient status including overall recovery, specific concerns from the patient, and any concerns raised by nursing staff] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) [significant events or changes in patient status since the time of admission or surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format using clinical terminology.) **Nutrition Status:** [fluid balance details, oral intake, IV intake, output from stoma, urine, catheter, NG tube, and drains, total fluid balance, and fluid deficit (positive or negative)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use bullet points with "-" and clinical acronyms. Do not write units.) **Mobility:** [patient's current mobility status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as short bullet points using "-".) **Today's Observations and Vitals:** [current vital signs and observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use bullet points using "-" and avoid writing units.) **Pain Status:** [assessment of patient's current pain level and management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format using acronyms for medications and techniques.) **Escalation Status:** [patient's current escalation status, such as Full, Ward Based, or DNACPR] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a brief sentence.) **Symptoms:** [any new or ongoing symptoms reported by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use paragraph or bullet format depending on content length.) **Current Medication:** [medications including antibiotics, fluids, analgesia, antiemetics, anticoagulation, specifying which are continued, stopped, or require further review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-". Use abbreviations such as IVABx, PO, SC, PRN, etc.) **Multidisciplinary Team Input:** [input from the pain team, stoma nurse, physiotherapy, dietitian, or other specialty reviews during the admission] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".) **Today's Ward Plan:** [detailed plan for the patient's care for the current day] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph or bullet point format using "-".) **Discharge Plan:** [plan for patient discharge] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph or bullet point format.) **Follow-up Plan:** [details of any planned follow-up appointments or care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list using "-".) **Jobs:** [tasks to be completed, such as chasing investigations, requesting reviews from other parties, or preparing discharge summaries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Use a bulleted list with "-".) **Patient and Doctor Conversation:** [summary of the conversation between the patient and the doctor, and interactions with other individuals present such as nurses, pain nurses, or family members] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Do not write units for vitals and investigations. Use medical and investigations acronyms throughout the conversation.)