Postoperative Follow-Up Note (Plastic Surgery)

Date: [Date]

Location: [Clinic location]

Provider: [Name, credentials]

Visit Type: [routine postoperative follow-up / urgent post-op evaluation]

Index Procedure: [Procedure name with laterality/site]

Date of Surgery: [Date]

Postoperative Day/Week: [POD# / POW#]

Subjective

[Recovery course since last contact] (Summarize overall trajectory as improving/stable/worsening; include adherence to postoperative instructions such as wound care, compression/garments, activity restrictions, and nicotine avoidance; note functional status including ADLs, sleep quality, mobility, and return-to-work readiness. Write as concise narrative.)

[Targeted symptom screen] (Document pertinent positives and negatives for: infection signs, bleeding or fluid collection, wound integrity concerns, and VTE symptoms when clinically relevant. Include procedure-specific screens only when applicable. Do not infer absence of symptoms—only include items explicitly asked or assessed.)

[Pain] (Include severity, location, functional impact, current analgesic regimen, and any medication side effects. If numeric pain score not obtained, use observational descriptors.)

[Drains, if applicable] (If present, record per-drain output volume and trend, character of drainage, and any system issues. Note whether a patient drain log is available. If unavailable, document explicitly and include the patient's estimate with statement of accuracy limitations.)

Objective

Exam Context: [in-person examination / telehealth: real-time video / telehealth: submitted photos] (If telehealth, specify what was visualized and state examination limitations.)

Vitals: [Relevant vitals if obtained] (If not obtained, state reason rather than omitting.)

General: [Appearance, distress level, ambulatory status]

Surgical Site Exam: [Incision status, drainage or exudate, surrounding skin findings, any collections, skin viability, closure status] (For flaps: include color, turgor, capillary refill, and Doppler findings if used. For grafts: include take percentage and adherence. Use measurements when clinically useful.)

Drains: [If present: type, location, patency, suction status, output volume and character per drain]

Results Reviewed: [Labs, cultures, pathology, imaging, and/or patient-submitted photos reviewed today] (Omit if none reviewed.)

Procedures Performed Today: [Dressing change, drain removal, suture removal, aspiration, debridement, etc.] (Include indication, technique, patient tolerance, and aftercare instructions. Omit if none performed.)

Assessment

[Problem-oriented synthesis] (State whether postoperative healing is progressing as expected or if concerning features are present. If complications suspected or confirmed, name them with degree of certainty and supporting findings. Address pain control adequacy and functional recovery status. Do not introduce new subjective or objective data; synthesize what is documented above.)

Plan

• Wound Care: [Dressing regimen, bathing instructions, topical care; scar management timeline if appropriate]
• Drains: [Continue vs remove with rationale; output monitoring instructions; site care if removed] (Omit if no drains.)
• Pain Management: [Current regimen and any changes; bowel regimen if on opioids; safety counseling]
• Activity: [Restrictions, compression/garment plan, return-to-work guidance]
• Return Precautions: [Specific warning signs requiring contact, relevant to procedure performed]
• Follow-up: [Timing and purpose of next visit; communication plan]