CLINICAL STRUCTURE

A surgical follow-up note should include: * **Patient Information:** Name, date of birth, medical record number. * **Date of Surgery:** The date the original procedure was performed. * **Surgeon Information:** Name of the surgeon who performed the procedure. * **Procedure Performed:** A clear and concise description of the surgery. * **Diagnosis:** The reason for the surgery. * **Date of Follow-up Visit:** The date of the current appointment. * **Reason for Follow-up Visit:** e.g., routine post-op check, complication management, suture removal, etc. * **Subjective (Patient's Report):** * How the patient is feeling overall. * Any pain or discomfort (location, intensity, what makes it better/worse). * Any new symptoms or changes since the last visit. * Activity level and tolerance. * Diet and bowel/bladder function (if relevant). * Medication compliance and any side effects. * Wound healing (patient's perception). * **Objective (Physician's Findings):** * **Vital Signs:** Temperature, pulse, blood pressure, respiration rate, oxygen saturation (if applicable). * **General Appearance:** Well-appearing, comfortable, distressed, etc. * **Wound Examination:** * Location, size, appearance of incision(s). * Signs of infection (redness, swelling, warmth, drainage). * State of sutures, staples, or dressings. * Presence or absence of dehiscence (opening of the wound). * **Physical Examination (pertinent to the surgery):** This will vary greatly depending on the procedure. Examples include: * Abdominal exam (tenderness, distension, bowel sounds). * Extremity exam (range of motion, swelling, pulses). * Neurological exam. * Cardiopulmonary exam. * **Review of Diagnostic Tests:** * Any laboratory results from the follow-up period. * Any imaging studies (X-rays, CT scans, ultrasounds) ordered since the surgery or on the day of the visit. * **Assessment:** * A summary of the patient's current status. * Evaluation of wound healing. * Assessment of recovery progress. * Identification of any complications or issues. * Differential diagnoses if new symptoms have appeared. * **Plan:** * **Medications:** Any changes, new prescriptions, or continuation of current medications. * **Activity Restrictions/Recommendations:** Limitations on lifting, exercise, or returning to work. * **Dietary Recommendations:** If applicable. * **Wound Care Instructions:** How to care for the incision at home. * **Follow-up Appointments:** When the next visit should be, or when to schedule one. * **Referrals:** To other specialists if needed. * **Tests/Imaging Ordered:** New orders for labs or scans. * **Patient Education:** What was discussed with the patient regarding their recovery, warning signs, etc. * **Contingency:** What the patient should do if certain symptoms arise (e.g., when to call the office or go to the emergency room). * **Signature and Date:** The physician's signature and the date of the note.

The exact content changes depending on the procedure and the patient's progress. The goal is to leave a clear line of care for the team and the patient.

Procedure and evolution

Date and type of procedure, reason for check-up, perceived recovery, symptoms, discomfort, and changes since last evaluation.

Wounded and alerts

Assessment, wound findings, vital signs as appropriate, complications, restrictions, and signals requiring attention.

Instructions and control

Care, medications, activity, studies, review date, and criteria for contacting the team.