Daily Progress Note POD

Date/time
Heading – Ortho Note:
POD # ___ for ____

SOAP Format:

Subjective:
-Pain control
-SOB (shortness of breath)
-CP (chest pain), calf pain/swelling
-Mobility
Objective:
-AVSS (afebrile vital signs stable)
-Incision check
-ROM (range of motion)
-NVI (neurovascular intact)
Assessment:
-stable/unstable
-physiotherapy progression
Plan:
-Continue physiotherapy regime
-Anticipated date of discharge (home vs. rehab)
-Antibiotic status/cultures
-Dressing changes, D/C drain, etc.