For my mid-site evaluation, I presented three cases: one small bowel obstruction (SBO) and two cases of cholecystitis. For the SBO case, the patient was a 69-year-old female who presented to the emergency department with nausea, vomiting, and abdominal pain. Imaging later revealed a small bowel obstruction with a transition point near the pelvis. Upon further history taking, it was discovered that she had a prior hysterectomy with salpingo-oophorectomy. She was admitted to the surgical service for conservative management of SBO secondary to adhesions with nasogastric tube decompression. However, due to lack of improvement, management was later escalated to surgical intervention with exploratory laparotomy, small bowel resection, and lysis of adhesions.

During the evaluation, my site evaluator emphasized the importance of carefully documenting intake and output in postoperative patients, especially those who have undergone bariatric surgery. After bariatric procedures such as gastric bypass or sleeve gastrectomy, the stomach capacity is significantly reduced, which limits the amount of fluid patients can consume at one time. Additionally, many patients experience nausea, vomiting, or poor oral intake in the early postoperative period. Monitoring intake ensures that the patient is receiving adequate fluids, while urine output helps assess hydration status and renal perfusion.

My mid-site evaluation also clarified my understanding of SOAP notes and how to improve my progress notes. My evaluator noted that my write-ups resembled full history and physical examinations rather than SOAP notes. Since my second rotation was in surgery, SOAP or progress notes were preferred. I had previously assumed that SOAP notes were essentially shortened versions of H&Ps, which led me to include unnecessary information such as extensive review of systems. I learned that SOAP notes should focus on the patient’s current status during that encounter and highlight only the most relevant information. My previous notes lacked this focus and were somewhat disorganized. During the evaluation, my preceptor explained the correct structure of SOAP notes, the key components required, and areas where I could improve my documentation.

For my final site evaluation, I presented a case involving a postoperative complication of crepitus secondary to carbon dioxide insufflation. The patient was a 55-year-old female on postoperative day one following laparoscopic hiatal hernia repair with gastropexy. She presented with subcutaneous crepitus and tenderness in the supraclavicular region that radiated to the neck and bilateral lower jaw. A postoperative chest X-ray revealed bilateral subcutaneous emphysema and pneumothoraces.

During my final evaluation, my evaluator noted that my SOAP notes were significantly more organized and refined compared to my earlier write-ups. He also emphasized that crepitus can be a relatively common finding following laparoscopic hiatal hernia repair due to carbon dioxide insufflation during the procedure. Additionally, he advised avoiding vague terminology such as “lesions,” as the term is nonspecific and can refer to many different findings. Overall, the site evaluations were very helpful in improving my clinical documentation skills and strengthening my understanding of postoperative patient management.