Postoperative Follow-Up Note (Foot/Ankle Surgery)

Date: [encounter date]

Patient: [name]

Procedure: [procedure name and laterality] performed [date of surgery] ([postop timeframe])

Operating Surgeon: [name] (Include only if different from follow-up clinician.)

Chief Complaint

[Reason for visit and any additional patient concerns] (Use a brief patient-centered phrase.)

Interval History

[Introductory sentence establishing procedure, laterality, and postoperative timeframe]

[Interval postoperative course covering: overall trajectory (improving/stable/worsening); interim events such as calls or ED visits; pain location and severity trend; wound symptoms including drainage, redness, warmth, or separation; neurovascular symptoms such as numbness, tingling, or new weakness; adherence to weight-bearing and immobilization instructions; falls or device issues; PT/rehab engagement; relevant patient concerns or goals] (If the patient reports calf pain, leg swelling, dyspnea, or other DVT/PE-concerning symptoms, document explicitly.)

Objective

(Document only findings confirmed today. Do not auto-populate normal findings. If an expected element is not assessed, state the reason.)

Vitals: [vital signs] (Include only if obtained or clinically relevant; otherwise omit.)

Incision/Wound: [location, approximation, drainage (none/serous/sanguineous/purulent), erythema (none/localized/spreading), warmth, tenderness, suture/staple status, surrounding swelling/ecchymosis] (If not visualized due to cast/splint, document reason and what was assessed instead.)

Neurovascular: [perfusion and capillary refill; pulses (DP/PT palpable vs Doppler); sensation by relevant distributions; motor function of key movements]

Extremity Exam: [alignment, swelling, tenderness, ROM and strength if permitted] (If deferred due to restrictions, state reason.)

Imaging: [modality and views; comparison if applicable; key findings on alignment, hardware, and healing; clinician impression] (Include only if obtained or reviewed today; otherwise omit.)

Assessment

[Index postoperative problem]: [improving / stable / worsening] — [supporting findings from history, exam, and imaging]

[Additional postoperative complications or related issues with status and supporting findings] (Include only if applicable.)

[Unrelated problems addressed today] (Include only if applicable; label as non-postoperative.)

Plan

• Wound care: [dressing instructions; showering restrictions; topical treatments; suture/staple removal timing] (Include only what was discussed.)
• Weight-bearing: [NWB / TTWB / PWB (%) / WBAT] — [planned progression and timeframe] (Required.)
• Immobilization: [device type]; [wear schedule]; [skin check guidance]
• Rehabilitation: [PT order or home exercise program]; [precautions]; [timing to initiate or progress]
• Pain management: [multimodal regimen]; [opioid plan if applicable: medication, quantity, taper, refill decision]
• VTE prophylaxis: [medication and duration] (Include only if applicable.)
• Work/activity: [restrictions; return-to-work; driving guidance] (Include only if discussed.)
• Return precautions: [warning signs: fever, increasing redness/drainage, wound opening, worsening pain, new numbness/weakness/cool foot, calf pain/swelling; when and how to seek care] (Required.)
• Follow-up: [timing and purpose of next visit]

[Additional problem-specific plan elements] (Include only if applicable.)

Procedure performed today: [procedure name] for [indication]; [brief technique]; [findings]; [post-procedure neurovascular status]; [complications: none / describe] (Include only if a procedure was performed.)