Orthopedic Surgery Postoperative Follow-Up Note (Global Period)

Patient: [Patient full name], DOB: [Date of birth], MRN: [Medical record number]

Date/Time: [Encounter date and time]

Location: [Clinic or facility name]

Author: [Documenting clinician name and role]

Index Procedure: [Procedure name with laterality/site], Surgery Date: [Surgery date], Primary Surgeon: [Primary surgeon name]

Postoperative Day/Week/Month: [POD # / POW # / POM #] (Compute relative to surgery date; use institution's convention.)

Visit Type: [routine global post-op care / complication-focused / mixed visit]

Chief Concern

[Purpose of visit: post-op follow-up for the index procedure and primary focus of this encounter] (One to two concise lines. Include the named procedure and surgery date, plus today's focus such as wound check, ROM assessment, imaging review, or return-to-activity discussion.)

Interval History

[Recovery course since surgery or last visit] (Summarize overall trajectory and functional progress. Include current pain status and analgesic use, noting opioid tapering if applicable; patient-reported wound symptoms when relevant such as drainage, redness, fevers; rehab/PT attendance and adherence; directed screening for infection symptoms, VTE/PE symptoms including calf pain/swelling, chest pain, dyspnea; and any new neurovascular symptoms such as numbness, weakness, color/temperature changes. Document patient goals or concerns for this visit. If the patient cannot provide history, specify the historian and source. Do not infer symptom absence without confirmation.)

Objective

(Include only clinician-observed or measured findings from today. If any component is limited by telehealth, patient refusal, or safety concerns, state the limitation inline with the relevant finding.)

• Vitals: [Vitals if clinically relevant] (Include only if pertinent to concerns such as fever or hemodynamic status; omit line entirely otherwise.)
• General: [Appearance, comfort, distress level if notable]
• Operative Site Exam: [Incision status, dressing/brace/cast condition, edema/effusion, sutures/staples status] (For later visits when healed, a brief status statement suffices.)
• ROM: [Active and/or passive ROM in degrees for relevant joint(s)] (Note pain limitation or protocol restrictions if applicable.)
• Strength: [Key muscle groups pertinent to procedure, graded 0–5 or functional description]
• Neurovascular: [Sensation, motor function, pulses/perfusion in the operative extremity]
• Gait/Function: [Weight-bearing tolerance, assistive device use, functional observations] (Include if assessed.)
• Imaging/Labs Reviewed: [Studies obtained or reviewed with salient findings] (Summarize alignment, healing, hardware position as relevant.)

Assessment

[Postoperative status summary for index procedure] (State current phase, healing trajectory including incision/pain/swelling/function, key objective findings such as ROM and strength, and imaging summary if applicable. Then address any suspected or confirmed complications or comorbidities affecting recovery. Keep concise—avoid restating the full exam.)

Plan

• Activity/Weight-Bearing: [NWB / TTWB / PWB / WBAT]; [Brace settings and ROM restrictions]; [Lifting, driving, sport restrictions with criteria]
• Rehabilitation: [PT/OT orders, protocol phase, key exercises allowed/restricted, progression criteria]
• Wound Care: [Dressing instructions, showering guidance, suture/staple removal timing]
• Medications: [Analgesic plan with taper if applicable]; [DVT prophylaxis and duration]; [Other relevant meds]
• Follow-Up: [Next appointment interval]; [Imaging timing]; [Return precautions: fever, increasing redness/drainage, new numbness or weakness, calf pain/swelling, chest pain/dyspnea]
• Work/School/Sports: [Restrictions with dates and return criteria] (Include only if applicable.)

(If protocol details or required information are unavailable, explicitly state what is unknown and document interim instructions given.)

Unrelated Problem Evaluated (Separate from Postoperative Care)

(Include this section ONLY if a distinct, non-postoperative problem was addressed during this visit. Omit entirely if not applicable.)

HPI: [History for unrelated issue]

Exam: [Pertinent findings specific to the unrelated problem]

Assessment: [Clinical impression]

Plan: [Diagnostics, treatments, referrals, and follow-up for the unrelated problem]