Surgical SOAP Note Example: Post-Op Day 2 After Laparoscopic Appendectomy
A daily surgical progress note: is recovery on track, and is anything going wrong? Diet, bowel function, ambulation, the incisions, and clear discharge criteria.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Inpatient surgical progress notePatient: Fictional patient: 36-year-old man
SSubjective
POD # / procedure
Post-op day 2 after laparoscopic appendectomy for perforated appendicitis with localized purulent fluid (washed out).
Overnight events
Temperature 38.0 °C at 22:00, none since. No other events.
Symptoms
Pain 3/10 at the port sites, controlled on scheduled acetaminophen and ibuprofen; needed oxycodone once overnight. No nausea since post-op day 1. Passing flatus; no bowel movement yet. Tolerating clear liquids and hungry. Walked the hallway 4 times yesterday. Urinating without difficulty.
OObjective
Vital signs
T 37.4 °C (Tmax 38.0 °C), HR 86, BP 124/78, RR 16, SpO2 98% on room air.
Intake / output
In: oral 1,400 mL, IV 1,000 mL. Out: urine 1,900 mL. No drains.
Exam
Alert and comfortable. Abdomen soft, mildly distended, tender only around the port sites; no rebound or guarding; bowel sounds present. Three port-site incisions clean, dry and intact, without redness, induration or drainage. Calves soft and nontender.
Labs
WBC 11.8 (17.2 before surgery). Creatinine 0.8, potassium 3.9.
AAssessment
Status
POD 2 after laparoscopic appendectomy for perforated appendicitis, recovering as expected: bowel function returning, tolerating liquids, pain controlled on oral medicines, WBC falling. One low-grade temperature on the night of POD 1 without recurrence, most likely postoperative inflammation. Watching for intra-abdominal abscess (higher risk after perforation) and surgical site infection; neither evident today.
PPlan
Diet
Advance to a regular diet as tolerated.
Pain control
Acetaminophen 1 g by mouth every 6 hours (maximum 4 g a day), ibuprofen 600 mg by mouth every 6 hours with food, oxycodone 5 mg every 4 hours only as needed for severe pain. Senna nightly while taking opioids.
Activity / ambulation
Walk at least 4 times a day; incentive spirometer 10 times an hour while awake. No lifting over 10 lb for 2 weeks.
Antibiotics
Continue ceftriaxone 2 g IV daily and metronidazole 500 mg IV every 8 hours for a total of 4 days after source control (through POD 4). If discharged sooner, switch to amoxicillin-clavulanate 875 mg/125 mg by mouth twice daily to finish the course.
Lines / drains
Keep IV access while on IV antibiotics; remove before discharge. No drains.
DVT prophylaxis
Enoxaparin 40 mg subcutaneous daily; sequential compression devices while in bed; ambulation.
Disposition
Discharge expected tomorrow if tolerating a regular diet, pain controlled on oral medicines, afebrile for 24 hours and walking independently. Clinic follow-up in 2 weeks. Return for fever over 38.3 °C (101 °F), worsening abdominal pain, vomiting, or redness or drainage at the incisions.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
It opens with post-op day and procedure, so the reader knows where the patient should be in recovery.
The recovery checklist is all there: pain, nausea, flatus, diet, ambulation, urination.
Intake and output, drain status and the incisions are documented, along with a complication screen.
DVT prophylaxis and explicit discharge criteria are in the plan.
What students often miss
Drain output and character
DVT prophylaxis
Clear criteria for discharge
Surgery SOAP note template
A daily progress note: is recovery on track, and is anything going wrong?
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.