Postoperative Follow-Up Note (Oral and Maxillofacial Surgery)

Date/Time: [date and time]

Patient: [patient name and identifier]

Procedure/Injury: [index procedure or injury with laterality/site]

Date of Surgery/Injury: [date] — POD/Post-op Week: [number]

Surgeon: [surgeon name]

Reason for Visit

[Brief statement of visit purpose] (Use patient's own words in quotes for qualitative complaints such as bite change, numbness, or taste. For routine visits: "Routine post-op evaluation; no acute concerns.")

Interval History

[Patient-reported postoperative course including: symptom status (pain control effectiveness, swelling/bruising trend, bleeding, fever/drainage, trismus, oral intake, numbness/tingling distribution and change); medication use since surgery (analgesics taken with dose/frequency and effectiveness, antibiotic adherence if prescribed); wound care and instruction compliance; relevant behavioral factors affecting healing such as tobacco/vaping] (Clearly distinguish patient-reported information from clinician observations. If clinically important information is unavailable, document why and what action was taken.)

Objective

Vitals: [relevant vital signs] (Include only if clinically indicated, e.g., infection concern or systemic symptoms.)

General: [distress level, hydration, speech]

Extraoral: [swelling, ecchymosis, tenderness, lymphadenopathy, maximal mouth opening if trismus relevant, CN V/VII if trauma or nerve proximity]

Intraoral: [surgical site mucosa, incision status, sutures, socket/graft appearance, drainage, floor of mouth if infection concern, oral hygiene around hardware/implants]

Occlusion: [stable / changed]; [hardware/elastic status] (Include for trauma/ORIF/MMF; omit for routine extraction.)

Implant Assessment: [peri-implant soft tissue, clinical stability, tenderness] (Include for implant cases; note if probing deferred due to early healing.)

Imaging: [type, date, pertinent findings] (Include only if obtained or reviewed today.)

Assessment

• [Postoperative status line, e.g., "POD #7 s/p surgical extraction #17, #32"]
• [Healing status: healing within expected limits / delayed healing / suspected complication] (Support with key findings.)
• [Complications considered or ruled out based on case type: infection, alveolar osteitis, dehiscence, neurosensory deficit, malocclusion, implant instability]

Plan

Medications: [current analgesic plan] (Nonopioid preferred; if opioid prescribed, document PRN use, limited quantity, and safety counseling.) [Antibiotic status: continue / complete / not indicated] (Include brief reasoning.) [Rinse instructions]

Wound Care/Diet: [oral hygiene modifications, irrigation if indicated, diet stage, sinus precautions or MMF instructions as applicable]

Procedures Today: [suture removal / irrigation / dressing change / elastic adjustment / other] (Omit if none.)

Follow-up: [timing and purpose of next visit]

Return Precautions: [fever / increasing swelling / worsening trismus / difficulty swallowing or breathing / uncontrolled bleeding / purulent drainage / new or worsening numbness / bite change / inability to tolerate oral intake] (Include precautions relevant to case type.)