Pediatric Surgery Clinic Follow-Up Note

Date: [Encounter date]

Patient: [Patient full name]

DOB: [Date of birth]

Provider: [Clinician name and credentials]

Accompanying Adult: [Name and relationship to patient]

Historian: [Who provided history]

Chief Concern

[Reason for visit, including procedure name and date if post-operative, plus any specific concern]

Surgical Context

(Include only for post-operative follow-ups; omit entirely for non-post-operative visits.)

• [Index procedure and indication]
• [Pertinent perioperative course: same-day vs admitted, complications, drains/devices]
• [Pathology status: final result, pending, or no specimen]

Interval History

[Orienting statement of overall recovery trajectory since surgery or last visit]

[Narrative summary of recovery milestones: pain control and analgesia use, diet and hydration tolerance, bowel and bladder function, activity level and school/daycare attendance, fever or systemic symptoms, wound or device course as reported] (Use flowing narrative; add focused bullets only when needed for clarity.)

[Complications screen: explicit presence or denial of red-flag symptoms] (Include any intercurrent events such as ED visits, calls, or outside testing.)

[Pathology discussion if newly available: results reviewed, key finding, with whom discussed] (Include only if applicable.)

Objective

Vitals: [Relevant vitals obtained, or "not obtained"]

Weight: [Current weight in kg]

Exam: [General appearance, hydration, distress level; focused systems examination as indicated; wound/incision assessment using objective descriptors: approximation, erythema extent, drainage, tenderness, closure material status; device assessment if applicable]

Data Reviewed: [Labs, imaging, pathology, or outside records reviewed with dates] (Include only items actually reviewed today; omit if none.)

Assessment & Plan

[Overall postoperative status relative to expected recovery timeline]

[Primary problem or diagnosis]

[Brief assessment of current status]

• Wound Care: [Care plan, dressing guidance, suture/staple removal timing if applicable]
• Pain Management: [Analgesic plan, opioid weaning if applicable]
• Diet/Bowel: [Diet advancement, bowel regimen as needed]
• Activity Restrictions: [School/daycare return, sports/PE restrictions, lifting limits, bathing/swimming guidance with timeframes; state "no restrictions" if none apply]
• Education: [Key caregiver education provided; understanding confirmed]
• Return Precautions: [Specific red flags and where to seek care]
• Follow-Up: [Next visit timing; pending results with notification plan; PCP communication if indicated]

[Additional problem if applicable]

(Include only if an unrelated or separately billable problem was addressed; document distinctly from routine post-op care.)

[Assessment and plan for this problem]

(General instructions: Omit sections that do not apply; use explicit statements such as "not obtained" or "pending" rather than leaving fields blank; use kg for weight; avoid error-prone abbreviations.)