Sample Progress Note for a CABG Patient
A comprehensive post-CABG progress note should include vital signs, cardiovascular assessment, respiratory status, pain management, wound evaluation, medication management, and specific complication monitoring to optimize patient outcomes and reduce mortality. 1
Essential Components of a CABG Progress Note
Patient Identification and Vital Signs
- Patient demographics
- Date and time of note
- Vital signs (BP, HR, RR, temperature, oxygen saturation)
- Pain score (0-10 scale)
- Input/output status (24-hour fluid balance)
Subjective Assessment
- Patient's reported symptoms (chest pain, dyspnea, palpitations)
- Pain assessment (location, character, severity, aggravating/relieving factors)
- Sleep quality and psychological status
- Activity tolerance
Objective Assessment
Cardiovascular System
- Heart rate and rhythm
- Heart sounds (S1, S2, presence of S3, S4, murmurs)
- Peripheral pulses (radial, femoral, dorsalis pedis, posterior tibial)
- Capillary refill time
- Presence/absence of edema
- Hemodynamic parameters if available (cardiac output, cardiac index)
- ECG findings
Respiratory System
- Respiratory rate and pattern
- Breath sounds
- Oxygen requirements and delivery method
- Ventilator settings (if applicable)
- Arterial blood gas results (if available)
- Chest X-ray findings
Surgical Sites
- Sternal wound appearance (redness, drainage, dehiscence)
- Leg/arm harvest site appearance
- Chest tube sites (if present)
- Drainage amount, color, and consistency
Neurological Status
- Level of consciousness
- Orientation
- Motor and sensory function
- Presence of delirium or cognitive changes
- Stroke assessment if indicated
Laboratory Values
- Complete blood count (especially hemoglobin/hematocrit)
- Electrolytes
- Cardiac enzymes
- Coagulation profile
- Renal function tests
- Blood glucose levels
Assessment and Plan
Cardiovascular Management
- Current cardiac status and hemodynamic stability
- Antiplatelet therapy (aspirin 100-325mg daily should be initiated within 6 hours postoperatively) 1
- Beta-blocker therapy to reduce risk of postoperative atrial fibrillation 1
- Statin therapy (target LDL <100 mg/dL or <70 mg/dL for very high-risk patients) 1
- ACE inhibitor/ARB (especially for patients with EF ≤40%, hypertension, diabetes, or CKD) 1
- Anticoagulation plan if atrial fibrillation present 1
Pain Management
- Current analgesic regimen
- Effectiveness of pain control
- Plan for titration or adjustment
Respiratory Management
- Oxygen therapy requirements
- Pulmonary hygiene measures
- Deep breathing exercises and incentive spirometry
- Plan for ventilator weaning (if applicable)
Fluid and Nutritional Status
- Current diet
- Fluid restrictions/requirements
- Electrolyte replacement needs
Activity and Rehabilitation
- Current mobility status
- Physical therapy progress
- Cardiac rehabilitation referral plan 1
Wound Care
- Current wound care regimen
- Dressing changes schedule
- Signs of infection monitoring
Complication Monitoring
- Specific monitoring for:
Discharge Planning
- Anticipated discharge date
- Home care needs
- Follow-up appointments
- Patient education status
Special Considerations for Different Patient Subgroups
Patients with Left Ventricular Dysfunction
- More detailed hemodynamic monitoring
- Close monitoring for signs of heart failure
- Optimization of preload, afterload, and contractility 4
- Careful medication titration 3, 4
Elderly Patients (Age 70 and Older)
- Higher risk for complications
- More gradual mobilization plan
- Closer monitoring for cognitive changes
- Medication dosing adjustments 3
Diabetic Patients
- Strict glycemic control (continuous insulin infusion may be required)
- More frequent wound assessment
- Optimization of medical therapy 1
Patients with Renal Dysfunction
- Careful fluid management
- Medication dose adjustments
- Daily renal function monitoring
- Electrolyte management 3
Common Pitfalls to Avoid in Post-CABG Documentation
- Failing to document specific cardiac rhythm and hemodynamic parameters
- Incomplete assessment of all surgical sites
- Inadequate pain assessment and management plan
- Missing documentation of prophylactic measures (DVT prophylaxis, stress ulcer prophylaxis)
- Failure to address medication reconciliation
- Incomplete documentation of patient education provided
- Omitting the plan for cardiac rehabilitation 1
By following this structured approach to CABG progress notes, healthcare providers can ensure comprehensive documentation that facilitates optimal patient care, reduces complications, and improves mortality and morbidity outcomes.