Neurosurgery Follow-Up Note (Outpatient)

Encounter Date: [Encounter date]

Clinic Location: [Clinic location] — [in-person / telehealth]

Rendering Clinician: [Clinician name and credentials]

Visit Type: [routine follow-up / postoperative / wound check / imaging review / device check]

Procedure: [Procedure name] on [Procedure date], [Post-op day or week] (Include for postoperative visits only.)

Chief Complaint

[Primary reason for the visit, optionally in patient's words]

Interval History

[Time anchor referencing last visit date or postoperative interval]. [Symptom trajectory: improved / worsened / unchanged] with [current severity and functional impact on ADLs, ambulation, work, driving]. [Response to interval treatments such as physical therapy, injections, medications, bracing]. [Interval events since last visit: ED visits, hospitalizations, falls]. [Pertinent negatives explicitly assessed relevant to condition]. (For postoperative visits, include pain control and analgesic regimen with opioid taper status, mobility progression, brace/collar adherence if prescribed, and any signs of complications. If history is limited or obtained from collateral sources, state the limitation and source.)

Objective

Vitals: [Clinically pertinent vitals if relevant to decision-making] (Omit if not clinically relevant.)

Neurologic Examination: [Focused examination appropriate to condition including mental status, cranial nerves, motor strength with laterality and grading, sensory examination, reflexes, gait and balance, and provocative maneuvers as relevant] (Include only components actually assessed. Document any examination limitations such as telehealth or patient factors.)

Incision/Wound: [Location, approximation, erythema, tenderness, drainage, signs of dehiscence or CSF leak; staples/sutures removed today if applicable] (Include for postoperative or wound check visits only.)

Device: [Device type, current settings, adjustments made today with rationale, patient response] (Include for device-related visits only.)

Data Review

[For each imaging study reviewed: modality and body region, study date, comparison date if relevant, source (internal/outside), whether images personally reviewed or report only, and key findings relevant to today's decisions. Include relevant labs or pathology only if they affect current management. Note if outside imaging is unavailable and whether the plan is contingent on image review.] (Do not paste full radiology impressions. Omit section if no imaging or records reviewed.)

Assessment & Plan

(Use problem-oriented format in descending clinical priority. Omit any plan element not relevant to the problem.)

[Problem 1]: [Diagnosis or working diagnosis]

[Status/trajectory: improved / worsened / unchanged] — [Key supporting evidence from symptoms, exam, and/or imaging]. [Plan: diagnostics ordered with indication and timing; treatment or medication changes including taper schedules; activity restrictions and therapy referrals with goals; wound care instructions if applicable; options discussed and patient preference; care coordination and referrals; follow-up timeframe and prerequisites; return precautions with condition-specific warning signs].

[Problem 2]: [Diagnosis or working diagnosis]

(Include additional problems as needed using same format.)

[Status/trajectory] — [Key supporting evidence]. [Plan elements as above].