Postoperative Clinic Follow-Up Note (Global Period)

Date of Service: [date]
Patient: [patient full name]
Provider: [provider name, credentials]
Visit Type: Postoperative clinic follow-up (global period)
Index Operation: [procedure name / UNKNOWN—REQUIRED], [date / UNKNOWN—REQUIRED], POD [#]
Operating Surgeon: [name / same as today's provider]
Site/Laterality: [site and laterality / N/A]
Visit Related to Index Operation: [Yes / No]
Unrelated Problems Addressed Today: [None / brief summary] (If any, document fully in Assessment & Plan under separate problems labeled as unrelated.)

Chief Complaint

[Brief reason for visit] (Single line such as routine post-op check, wound concern, drain evaluation, pathology review.)

Interval History

[Postoperative course since surgery] (Open with chief complaint. Include pain control and trend; wound/incision concerns; drain output if applicable; diet tolerance and bowel function as relevant; mobility and activity; adherence to postoperative instructions; interim events such as ED visits or readmissions. Omit formal ROS unless symptoms raise concern for specific complications.)

[Postoperative medications reviewed/changed] (Include only if changes made; note analgesics, antibiotics, anticoagulation, bowel regimen as applicable.)

Objective

Vitals: [relevant vitals / not obtained]

Exam: [Pertinent findings] (General appearance and focused system findings relevant to the index surgery.)

Wound/Incision: [location and status] (Approximation, erythema, drainage, tenderness, suture/staple status, dressing condition. If not directly examined, state limitation.)

Drains: [type, location, output trend and character, site appearance, action taken] (Include only if drains present. For multiple drains, document each. Omit entirely if none.)

Data: [relevant labs, imaging, or pathology] (Summarize final results in clinician language. Note if reviewed with patient and impact on plan. Omit if no pertinent data.)

Procedure Performed: [procedure, indication, technique, tolerance, aftercare] (Include only if clinic procedure occurred. Omit if none.)

Assessment & Plan

(Problem-oriented format. Begin with postoperative status, then address wound, drains, pain, activity, and complications as separate problems. For each: brief assessment statement and actionable plan.)

Postoperative status — [index operation]

[Recovery trajectory: improving / stable / worsening]. [Findings consistent with expected recovery / concerning for complication].

• [Plan: monitoring, education, follow-up timing, escalation criteria]

Wound/Incision

[Wound healing status] (Infection signs, dehiscence, seroma/hematoma present or absent.)

• [Plan: wound care, dressing changes, suture/staple management, topicals or antibiotics if indicated]

Drains

[Drain output trend and site assessment] (Include only if drains present; omit if none.)

• [Plan: continue vs remove with criteria; if removed today, note reason and post-removal instructions]

Pain management

[Pain control: adequate / inadequate]. [Adverse effects: none / present].

• [Plan: analgesia adjustments, taper, bowel regimen if on opioids]

Activity and restrictions

[Current activity level and tolerance].

• [Plan: activity advancement, lifting restrictions with timeframe, DVT prophylaxis if applicable]

Complication(s)

[Complication if present] (Include only if applicable; omit if none.)

• [Plan: treatment, diagnostics, referrals, monitoring]

[Unrelated problem]: (unrelated to index operation)

[Assessment of unrelated issue] (Include separate entry for each unrelated problem addressed.)

• [Plan: diagnostics, treatment, referrals, follow-up]

Instructions & Follow-Up

(Patient-facing language. Include only applicable items.)

• Wound care: [care instructions and dressing guidance]
• Drain care: [daily care, output logging, when to call] (If applicable.)
• Activity: [allowed activities, lifting limits, driving, return-to-work with timeframe]
• Diet/Bowel regimen: [diet progression and bowel regimen] (If applicable.)
• Medications: [analgesia plan; antibiotics/anticoagulation if applicable]
• Return precautions: [fever, worsening pain, wound changes, bleeding, calf pain/swelling, shortness of breath, other specific concerns]. Call [contact] or seek emergency care for [urgent symptoms].
• Next follow-up: [date/timeframe] for [purpose].
• Pending results: [tests pending, owner, expected timeframe] (If any.)
• Referrals: [referrals placed and reason] (If any.)