Bariatric Surgery Longitudinal Follow-Up Note

Date: [date of service]

Provider: [name and role]

Visit Type: [in-person / telehealth]

Surgical History

[procedure type (SG, RYGB, BPD/DS, AGB, etc.)], [surgical date], [time since surgery]. Surgeon/facility: [if known]. Complications/revisions: [list with dates / none documented]. (If procedure type or surgical date is unknown, state what is missing and the plan to obtain records.)

Weight Trajectory

• Pre-op: [weight and/or BMI / not available]
• Nadir: [weight and date / not available]
• Last visit: [weight and date]
• Today: [weight and BMI]
• Metrics: [%TWL or %EWL if program uses; weight change from nadir]

(If historical weights are unavailable, note plan to obtain.)

Interval History

[Brief narrative summary of interval course: weight trajectory, adherence themes, new symptoms or complications, significant events such as hospitalizations or medication changes] (3–5 sentences.)

(Include only domains assessed and relevant. Omit headers for domains not addressed. If a safety-relevant domain was not assessed, state "not assessed today" with rationale.)

Nutrition/Intake: [eating pattern; estimated protein intake; fluid adequacy; problem behaviors (grazing, liquid calories, speed of eating); alcohol use]

GI Tolerance: [dysphagia; nausea/vomiting; reflux; abdominal pain; bowel changes; dumping symptoms; hypoglycemia symptoms with timing relative to meals] (Flag red flags: GI bleeding, inability to tolerate fluids, progressive dysphagia, severe pain.)

Supplements: [current regimen with adherence; bariatric-specific vs standard formulation; barriers to adherence]

Activity/Function: [exercise type and frequency; functional limitations]

Comorbidities: [status update for each relevant condition with key data (diabetes/A1c, hypertension/home BPs, OSA/CPAP use, GERD, etc.); medication changes since last visit]

Medications: [confirmed current list] (Explicitly document NSAID use, acid suppression, anti-obesity pharmacotherapy, and agents with absorption concerns.)

Objective

Vitals: [weight, BMI, BP, HR; delta from last visit] (If telehealth, note whether patient-reported.)

Exam: [pertinent findings—general appearance; abdominal exam; skin/hair/nails if deficiency suspected; neurologic if indicated]

Labs: [results organized by category as relevant: hematology/iron, B vitamins, bone/mineral (calcium, vitamin D, PTH), metabolic (A1c, lipids), fat-soluble vitamins and trace minerals if malabsorptive procedure; include test name, date, result, and interpretation for each] (State whether surveillance is current for procedure type. If labs are overdue or missing, document plan to obtain.)

Diagnostics: [relevant imaging, endoscopy, or other studies with date and key findings]

Assessment

(Numbered problem list in descending clinical priority. Each problem includes a concise assessment with supporting evidence. Include differential diagnosis only when clinical uncertainty exists.)

1. Post-bariatric surgery status: [weight trajectory assessment—expected vs concerning—with supporting data]
2. Micronutrient status: [deficiencies or risk states with supporting labs/symptoms]
3. GI tolerance/complications: [reflux, dysphagia, marginal ulcer risk, dumping, hypoglycemia as applicable]
4. Comorbidity control: [diabetes, hypertension, OSA, GERD, etc., with key objective data]
5. [additional problems as applicable]

Plan

(Organize by problem number. Use action-oriented language.)

1. [Problem name]: [specific interventions—behavioral targets, supplement adjustments, repletion strategies, medication changes, referrals, labs ordered, monitoring intervals]
2. [Problem name]: [specific interventions]
3. [additional problems as needed]

Safety/Return Precautions: [tailored to patient risk—signs of dehydration, GI bleeding, severe pain, neuroglycopenic symptoms]

Follow-up: [interval; modality; pre-visit requirements (labs, dietitian visit, food log)]

Education/Shared Decision-Making: [topics discussed; patient preferences and decisions for significant changes]

(Handling missing information: Use "unknown" when patient does not know and records unavailable; "not assessed today" when intentionally deferred; "not applicable" when contextually irrelevant.)