Bariatric Surgery Discharge Summary

Patient: [Full name], [MRN], [DOB]

Admission Date/Time: [Admission date and time]

Discharge Date/Time: [Discharge date and time]

Attending Surgeon: [Surgeon name and credentials]

Procedure: [Procedure name] ([laparoscopic / robotic / open] approach), [Procedure date]

Discharge Disposition: [home / home with services / SNF / acute rehab / other]

Admission Indication

[Reason for admission] (Summarize in 1–3 sentences whether this was an elective metabolic/bariatric surgery admission or a readmission for complication evaluation. Include key preoperative diagnoses driving the admission.)

Discharge Diagnoses

(List primary discharge diagnosis first, followed by secondary diagnoses and relevant comorbidities. List any in-hospital complications as distinct diagnoses with dates. Include procedure status as a diagnosis when appropriate. Label diagnoses pending confirmation as provisional.)

• Primary: [Primary discharge diagnosis]
• [Secondary diagnosis or comorbidity]
• [In-hospital complication with date, if applicable]
• [Provisional diagnosis pending confirmation, if applicable]

Procedures Performed

(List each procedure with date and approach. Include concurrent procedures. Provide a 2–4 sentence operative summary focused on findings relevant to follow-up, intraoperative complications, and drains placed. Reference operative report for full details.)

• [Procedure name]: [Approach] — [Date]
  Concurrent procedures: [Concurrent procedures, or "None"]
  Operative summary: [Key findings, anastomoses/staple lines, hemostasis, EBL if relevant, intraoperative complications if any, drains placed with locations. Reference operative report for details.]
• [Additional procedure/intervention]: [Name] — [Date] — [Indication and key findings] (Include if additional procedures performed during stay.)

Hospital Course

(Use problem-oriented format with problems listed in descending clinical severity. For each problem, describe what occurred, key diagnostics/interventions with reasoning, and status at discharge. Avoid day-by-day narrative.)

[Problem 1 title]

[Course summary including onset, evaluation, management, response, and status at discharge. Include dates for significant events.]

[Problem 2 title]

[Course summary] (Repeat as needed for additional problems.)

Postoperative Recovery

• Diet tolerance: [Current stage], [tolerating / limited / not tolerating], [approximate intake], [vomiting status and management if applicable]
• Ambulation: [Independent / assisted / limited], [distance/frequency if documented]
• Pain control: [Oral / IV / multimodal] regimen, [adequacy]
• Nausea/vomiting: [Present / absent], [antiemetic regimen and response]
• Hydration status: [Adequate / marginal / dehydrated]
• Respiratory status: [Room air / supplemental oxygen], [OSA/CPAP plan if applicable]
• VTE prophylaxis: [Inpatient approach], [extended prophylaxis plan if applicable]
• Glycemic management: [Diabetes status, medication adjustments, hold/restart instructions] (Only include if applicable.)

Complications: [Description of any complications with dates, evaluation, treatment, and outcomes. If none, state: "No surgical or medical complications during this hospitalization."]

Condition at Discharge

[Hemodynamic stability; pain control status and route; diet stage and tolerance with approximate intake and vomiting status; ambulation level; wound/incision and drain status if present; respiratory status including CPAP plan if OSA. End with global assessment: stable / improved / at baseline.]

Discharge Medications

(Provide reconciled medication list with name, dose, route, frequency, and duration/stop date for time-limited medications. Include indication for new or high-risk medications. Note bariatric formulation requirements where applicable. If home medication history was incomplete, state limitations and sources used.)

• [Medication]: [Dose] [Route] [Frequency] — [Duration if time-limited] — [Indication if new/high-risk] [Formulation note if applicable]

(For bariatric patients, explicitly address when applicable: VTE prophylaxis with duration; PPI with intended duration; ursodiol for gallstone prevention; analgesics with constipation prophylaxis; antiemetics scheduled and PRN; glycemic medications with hold/restart instructions; antihypertensives/diuretics with any holds for dehydration risk.)

Medication Changes:

• Started: [Medications with rationale]
• Stopped: [Medications with rationale]
• Changed: [Medications with rationale]

Important: Avoid NSAIDs due to ulcer risk after bariatric surgery unless explicitly directed by the bariatric team.

Diet, Nutrition, and Supplements

Discharge Diet Stage: [Program-specific stage name] — [Brief description of allowed textures/liquids]. Hydration goal: [target oz/day]. Protein goal: [target g/day]. Key techniques: small sips, avoid drinking with meals, no carbonation or alcohol.

Vitamin/Mineral Supplementation: [Bariatric multivitamin], [Calcium with form and divided dosing], [Vitamin D], [Vitamin B12], [Iron if indicated]. Supplementation is lifelong. Contact clinic promptly if experiencing persistent vomiting or poor intake due to thiamine deficiency risk.

(Reference program diet protocol for food lists and progression timing. Include dietitian follow-up plan.)

Activity and Restrictions

• Ambulation: [Walk frequency / as tolerated]; leg exercises encouraged for VTE prevention
• Lifting: No lifting > [weight limit] for [duration]
• Driving: [No driving while taking opioids / may resume when off opioids and able to react safely]
• Work/school: [Anticipated return timeframe / pending follow-up assessment]
• Incentive spirometry: [Use frequency as instructed] (Include if applicable.)

Wound and Drain Care

(Only include this section if incisions or drains require specific care instructions.)

• Incisions: [Dressing care], [shower guidance], [signs of infection to monitor], [staple/suture removal timing]
• Drains: [Type and location], [emptying schedule], [record output instructions], [criteria to call clinic], [anticipated removal plan] (Include if drains present.)

Follow-up Plan

• Bariatric surgery clinic: [Date/timeframe] — [Purpose]
• Dietitian: [Date/timeframe] — [Nutrition progression and supplementation review]
• Primary care: [Date/timeframe] — [Medication reconciliation and comorbidity management]
• Specialist: [Specialty type] — [Date/timeframe] — [Reason] (Include if applicable.)
• Labs/Monitoring: [Tests] — [Timing] — [Responsible clinician/service]

(If appointments not yet scheduled, specify scheduling deadline and responsible party.)

Pending Results

(If none, state: "No pending tests or studies at discharge.")

• [Test name] — [Date obtained] — [Expected timeframe] — [Responsible clinician/service for follow-up]

Return Precautions

Call bariatric clinic/on-call for:

• Persistent vomiting or inability to maintain hydration
• Worsening abdominal pain
• Fever or chills
• Wound redness, drainage, or increasing pain
• Dizziness or near-syncope
• Uncontrolled pain despite medications
• Signs of dehydration (decreased urine output)

Go to ED or call 911 for:

• Chest pain or shortness of breath
• Unilateral leg swelling or pain
• Significant bleeding (vomiting blood, black stools)
• Severe abdominal pain with rapid heart rate
• Confusion or altered mental status

24/7 Contact: [Bariatric team/on-call number]