Structured Progress Note Format for CABG Patient on POD2
Progress notes for a CABG patient on POD2 should follow a comprehensive SOAP format with specific attention to cardiovascular parameters, respiratory status, fluid balance, pain management, and early mobilization to optimize outcomes and reduce complications.
Patient Identification and Vital Signs
- Date/time of note
- Patient demographics (name, MRN, DOB)
- Post-op day #2 CABG clearly indicated
- Current vital signs with trends (BP, HR, temperature, respiratory rate, oxygen saturation)
- Hemodynamic parameters if available (CVP, cardiac output)
Subjective
- Pain level and location (sternotomy site, leg/arm harvest sites)
- Respiratory comfort/distress
- Sleep quality
- Mobility status/tolerance to activities
- Patient concerns
Objective
Cardiovascular Assessment
- Heart rhythm and telemetry findings (note any arrhythmias, particularly atrial fibrillation which occurs in up to 30% of post-CABG patients) 1
- Heart sounds (murmurs, rubs, gallops)
- Peripheral pulses and perfusion
- Chest tube drainage (amount, color, trends)
- Mediastinal/pleural drainage if present
- Wound assessment (sternotomy and graft harvest sites)
Respiratory Assessment
- Respiratory pattern and effort
- Breath sounds
- Oxygen requirements and delivery method
- Ventilator settings if applicable
- Arterial blood gas results if available 1
Neurological Assessment
- Level of consciousness
- Orientation
- Motor and sensory function
- Presence/absence of delirium or cognitive changes
- Any focal neurological deficits 1
Fluid Balance
- Intake and output (last 24 hours)
- Net fluid balance
- Urine output (hourly rate)
- IV fluids (type, rate)
Laboratory Values
- Complete blood count (focus on hemoglobin/hematocrit trends)
- Coagulation profile
- Electrolytes
- Renal function (BUN, creatinine)
- Cardiac enzymes
- Glucose levels
Assessment
- Overall clinical status and progress since POD1
- Cardiovascular status (stable vs. requiring intervention)
- Respiratory status (weaning from oxygen or requiring support)
- Wound healing status
- Pain control adequacy
- Fluid status (euvolemic, hypovolemic, hypervolemic)
- Specific complications if present:
- Arrhythmias (particularly atrial fibrillation)
- Bleeding
- Respiratory issues
- Neurological complications
- Renal dysfunction
Plan
Cardiovascular
- Antiplatelet therapy (aspirin and P2Y12 inhibitors if indicated) 2, 1
- Beta-blocker therapy (particularly for prevention of post-operative AF) 2, 1
- Statin therapy 2, 1
- ACE inhibitors/ARBs (especially for patients with LVEF ≤40%, hypertension, diabetes, or CKD) 2
- Chest tube management (removal criteria)
- Telemetry monitoring plan
Respiratory
- Oxygen therapy plan (weaning parameters)
- Pulmonary hygiene (incentive spirometry, deep breathing exercises)
- Chest physiotherapy if indicated
Fluid/Electrolytes
- IV fluid plan (type, rate, duration)
- Electrolyte replacement if needed
- Diuretic therapy if indicated
Pain Management
- Analgesic regimen (transition from IV to oral)
- Non-pharmacological pain management strategies
Activity/Mobility
- Physical therapy plan
- Activity progression goals
- Early mobilization protocol
Nutrition
- Diet advancement
- Dietary restrictions if applicable
Wound Care
- Dressing changes (frequency, type)
- Wound assessment schedule
Discharge Planning
- Anticipated discharge date
- Discharge destination
- Home care needs assessment
- Follow-up appointments 1
Common Pitfalls to Avoid
- Failing to document cardiac rhythm and hemodynamic stability, which are critical for early detection of complications
- Overlooking neurological assessment, as stroke is a significant post-CABG complication 2
- Inadequate documentation of respiratory status, which can lead to delayed recognition of respiratory complications
- Incomplete medication reconciliation, particularly antiplatelet and anticoagulant therapies
- Missing documentation of glycemic control in diabetic patients 1
- Failing to address special considerations for elderly patients (>70 years) who are at increased risk for complications 2, 1
By following this structured format, the progress note will provide comprehensive documentation of the patient's status on POD2 after CABG surgery, facilitating effective communication among the healthcare team and optimizing patient outcomes.