Otolaryngology Postoperative Follow-up Note

Date: [Date]

Patient: [Patient full name and identifier]

Provider: [Provider name, credentials]

Encounter Type: [Office / Telehealth - video / Telehealth - audio-only]

[Surgical anchor line: POD#[number] s/p procedure name(s) with laterality (surgery date, surgeon of record)]

Chief Complaint: [Single-line reason for visit]

Interval History

[Narrative postoperative course since surgery] (Summarize key events since the operation including ED visits, readmissions, or urgent calls if any. Cover focused symptom screen: bleeding, fever or infection signs, pain control adequacy, wound concerns, and procedure-relevant symptoms as applicable. Include functional status such as diet and hydration tolerance, activity level, and sleep. Note current postoperative medications and response, and adherence to wound care instructions. Use brief direct quotes sparingly for high-salience symptoms. For safety-critical symptoms asked and denied, document "denies." If a critical symptom could not be assessed, state "not assessed" rather than omitting. Include a brief patient-reported outcome statement when relevant.)

Objective

Vitals: [Relevant vitals] (Note measurement source. For telehealth, indicate patient-reported or unavailable. Omit if not obtained.)

Exam: [Focused physical examination tied to surgical site] (Begin with general appearance, then document pertinent findings specific to the operated region. For telehealth, state exam limitations by modality and describe what was visualized; note if patient-submitted photos were reviewed with upload date. Do not document systems not examined.)

Wound/Site Assessment: [Incision or surgical cavity status, surrounding tissue, drainage, sutures/staples/dressing status, and devices or packing if present] (Describe healing status and any concerns. Omit if not applicable to procedure type.)

Procedure(s) Today: [Procedure name, indication, brief technique, key findings, patient tolerance, and specimens sent if any] (Include only if a procedure was performed during this visit. Omit entirely otherwise.)

Results Reviewed: [Pathology, labs, or imaging reviewed with key findings and clinical implications] (For pathology, include specimen type, final diagnosis, and margin status if applicable. If results are pending, note expected timing and communication plan. Omit if no results reviewed.)

Assessment

• [Postoperative status]: [Procedure and date; healing trajectory: healing as expected / complicated by specified issue]
• [Complication if present]: [Brief status statement] (Include only if applicable.)
• [Pathology-driven diagnosis if applicable]: [Staging or management implications] (Include only if malignancy or significant pathology identified.)

(List problems in descending clinical priority. Keep entries brief.)

Plan

Wound/Site Care: [Cleaning method, topical treatments, irrigations, dressing changes, and device management with frequency and duration]

Medications: [Medication changes with drug, dose, route, frequency, duration or stop date, and indication] (Include pain regimen adjustments and any new prescriptions.)

Activity/Diet: [Restrictions and guidance with specific time anchors] (Include return-to-work, exercise, and procedure-specific precautions such as lifting limits, water precautions, or voice rest as applicable.)

Results Discussion: [Summary of counseling and next steps if pathology or significant results were reviewed] (Document patient understanding and downstream plans such as referrals or additional workup. Omit if no results discussion occurred.)

Follow-Up: [Timing and modality of next appointment, what will be assessed, and contingency for earlier evaluation if needed]

Return Precautions

• Call office for: [Non-emergent concerns such as persistent low-volume bleeding, increasing localized redness or drainage, worsening pain not controlled with prescribed regimen, device or packing concerns]
• Go to ED or call 911 for: [Emergencies such as brisk or uncontrolled bleeding, rapid swelling or expanding hematoma, fever with worsening wound signs, severe uncontrolled pain, difficulty breathing or stridor, inability to handle secretions]
• Procedure-specific warnings: [Add relevant red flags tailored to the operated region] (Omit if general precautions are sufficient.)