Bariatric Surgery Post-Op Clinic Follow-Up Note (Early)

Date: [Date]

Post-op interval: [Postoperative week and procedure details, including procedure name, surgical approach, and primary vs revision]

Encounter type: [in-person / telehealth] (If telehealth, specify modality and note examination limitations.)

Operating surgeon/facility: [Operating surgeon and facility] (Include if care is shared across providers; otherwise omit this line.)

Chief Complaint

[Reason for visit: routine early post-op follow-up or symptom-driven concern(s); include brief patient quote when relevant]

Subjective

[Brief postoperative course summary in 3–5 sentences: hospital course highlights, any ED visits or readmissions with dates, overall recovery trajectory] (If details are unavailable, state "Not available" and note plan to obtain records.)

Hydration: [Estimated daily fluid intake in oz or L; pattern and barriers; dehydration signs including urine frequency/color, dizziness, dry mouth] (Quantify when possible. If not tracked, note "estimated.")

Nutrition: [Estimated daily protein intake in g/day with sources; current diet stage; tolerance issues including nausea, vomiting, dysphagia, food sticking, reflux, dumping symptoms; eating behaviors] (Quantify intake and episodes/day when possible.)

Supplements: [Started / not started]; [Formulation: chewable / liquid / tablet]; [Tolerance] (If not started, document reason and plan.)

Pain and function: [Pain location, severity, trend]; [Current analgesics and side effects]; [Activity level and return-to-work status]

Red-flag screen: (Explicitly document each; do not use blanket "denies red flags.")

• Fever/chills: [present / absent / unknown]
• Tachycardia/palpitations/syncope: [present / absent / unknown]
• Chest pain/dyspnea: [present / absent / unknown]
• Calf pain/swelling: [present / absent / unknown]
• Severe or escalating abdominal pain: [present / absent / unknown]
• Inability to tolerate liquids: [present / absent / unknown]
• Persistent vomiting: [present / absent / unknown]
• GI bleeding signs: [present / absent / unknown]
• Neurologic symptoms (confusion, ataxia, vision changes, neuropathy): [present / absent / unknown]
• Wound infection signs: [present / absent / unknown]

Medications: [Current medications]; [Medications stopped or held]; [Acid suppression regimen]; [Antiemetic regimen]; [Anticoagulation status]; [Diabetes medication changes]; [NSAID use: yes / no] (If NSAID use present, document counseling provided.)

Wound self-report: [Patient-reported incision status]; [Photos submitted / incision visualized on video / not visualized]

Comorbidity status: [Relevant home monitoring data and symptoms] (Include only if active changes or monitoring needs; otherwise omit this line.)

Objective

Vitals and weight: [HR, BP, Temp, SpO2]; [Current weight and BMI]; [Weight change since surgery and/or last visit] (Note if patient-reported for telehealth. Include orthostatics if low intake or dizziness reported.)

Exam:

• General/hydration: [Appearance, mucous membranes, hydration status]
• Cardiopulmonary: [Heart rate and rhythm, respiratory effort]
• Abdomen: [Tenderness, distention, peritoneal signs]
• Incisions: [Erythema, drainage, dehiscence, staple/suture status] (If telehealth and not visualized, state "Incisions not examined (telehealth limitation).")
• Extremities: [Edema, calf tenderness] (Include if VTE concern; otherwise omit.)

Data reviewed: [Documents reviewed and relevant findings] (If none, state "No external records reviewed.")

Assessment and Plan

Post-op status

[Procedure, postoperative week, course uncomplicated / complicated]; [Recovery trajectory: improving / plateau / worsening]; [Statement whether current presentation raises concern for urgent complication] (If concern present, specify suspected complication and immediate actions.)

Hydration/nutrition

[Assessment of fluid and protein intake adequacy]; [Interventions: sipping schedule, antiemetic optimization, oral rehydration]; [Escalation thresholds for IV fluids or urgent evaluation]

Diet advancement

[Current stage]; [Readiness criteria for next stage]; [Protein-first and behavioral counseling provided]

Nausea/vomiting/GI symptoms

[Differential considered]; [Medication changes]; [Thiamine risk assessment and supplementation plan if vomiting or poor intake present]; [Escalation criteria] (Include only if symptoms present; otherwise omit this section.)

Wound

[Current status]; [Care instructions]; [Staple/suture removal plan and timing if applicable]

Supplements

[Current regimen]; [Tolerance and adherence]; [Plan for non-adherence or intolerance if applicable]

Medication changes

[Changes to chronic disease medications with rationale]; [Home monitoring instructions and parameters for when to call]

Follow-up and orders

[Next visit timing]; [Return precautions for earlier evaluation]; [Surveillance labs: ordered now or planned at specific timepoint]

Orders placed: [Labs, imaging, medications, referrals with indications] (If none, state "No orders placed.")

(Use explicit labels such as "Unknown," "Not assessed," "Not available," or "Telehealth limitation" rather than leaving fields blank. Quantify values when possible. Use specific dates rather than "recently.")