Post-CABG Progress Note Template
A comprehensive post-CABG progress note should include vital signs, hemodynamic parameters, respiratory status, neurological assessment, cardiovascular examination, wound assessment, fluid balance, laboratory values, medication review, and a clear plan for each system. 1
Patient Identification and Vital Information
- Patient name, ID, age, gender
- Date of surgery and current post-operative day
- Type of CABG performed (on-pump vs. off-pump)
- Number and location of grafts placed (e.g., LIMA to LAD, SVG to OM)
- Surgeon name and team
Vital Signs and Hemodynamic Parameters
- Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation
- Hemodynamic measurements if applicable (CVP, cardiac output)
- Pain score (0-10 scale)
Cardiovascular Assessment
- Heart sounds and rhythm
- Presence/absence of murmurs, rubs, or gallops
- Peripheral pulses (document all extremities)
- Telemetry findings and any arrhythmias (particularly atrial fibrillation which occurs in up to 30% of post-CABG patients) 1
- Chest tube drainage (amount, color, consistency)
- Pacemaker dependency if applicable
Respiratory Assessment
- Respiratory pattern and effort
- Breath sounds in all fields
- Oxygen requirements and delivery method
- Ventilator settings if intubated
- ABG results if applicable
- Chest X-ray findings
- Pulmonary function (incentive spirometry volumes)
Neurological Assessment
- Level of consciousness and orientation
- Motor and sensory function
- Presence/absence of delirium or cognitive changes
- Any focal neurological deficits (particularly important given risk of post-CABG stroke) 1
Surgical Site/Wound Assessment
- Sternal wound appearance (erythema, drainage, dehiscence)
- Leg/arm harvest site appearance (if applicable)
- Presence/absence of signs of infection
- Sternal stability
Fluid, Electrolyte, and Renal Status
- Intake and output (24-hour totals)
- Fluid balance
- Urine output (hourly if in ICU)
- Renal function parameters
- Electrolyte values and replacements
- Weight change from baseline
Laboratory Values
- Complete blood count (particularly hemoglobin/hematocrit)
- Basic metabolic panel
- Cardiac enzymes if indicated
- Coagulation profile
- Inflammatory markers if infection suspected
Medication Review
- Antiplatelet therapy (aspirin +/- P2Y12 inhibitor) 1
- Beta-blockers 1
- Statin therapy 1, 2
- ACE inhibitors/ARBs if indicated 1, 2
- Anticoagulation if applicable
- Pain management regimen
- Insulin/glycemic control
- Prophylactic medications (DVT, stress ulcer)
Systems Review and Plan
- Cardiovascular plan (rate/rhythm control, hemodynamic goals)
- Respiratory plan (oxygen weaning, extubation criteria if applicable)
- Neurological plan (delirium management if present)
- Infectious disease (antibiotic plan, fever workup if applicable)
- Renal/Fluid (diuresis goals, fluid management)
- Gastrointestinal (diet advancement, bowel regimen)
- Endocrine (glucose management)
- Rehabilitation plan (physical therapy, cardiac rehabilitation referral)
- Pain management plan
Discharge Planning
- Anticipated discharge date
- Discharge destination (home vs. rehabilitation facility)
- Home care needs assessment
- Follow-up appointments (surgeon, cardiologist, primary care)
- Patient education needs (medication adherence, activity restrictions, wound care)
Special Considerations
- For elderly patients (>70 years): Note increased risk for complications and potentially longer recovery 1
- For diabetic patients: Document glycemic control strategy 1
- For patients with renal dysfunction: Note fluid restrictions and medication adjustments 1
- For patients with respiratory disease: Document specialized respiratory care plan 1
Common Pitfalls to Avoid
- Failing to document medication adherence issues which affect long-term outcomes 2, 3
- Overlooking signs of early sternal wound infection which increases mortality 1, 4
- Inadequate pain control leading to respiratory complications 4
- Missing early signs of graft failure (new ECG changes, enzyme elevations) 5
- Neglecting psychosocial factors that impact recovery (anxiety, depression, social support) 6
Daily Assessment Questions
- Is the patient hemodynamically stable?
- Are there any new arrhythmias?
- Is respiratory status improving?
- Are there any signs of infection?
- Is pain adequately controlled?
- Is the patient meeting expected recovery milestones?
- Are there any barriers to discharge planning?
This structured approach ensures comprehensive documentation and monitoring of post-CABG patients, facilitating early identification of complications and optimizing outcomes.