Postoperative Follow-Up Visit Note (Gynecologic Surgery)

Date/Time: [Encounter date and time]

Provider: [Clinician name and credentials]

Encounter Type: [in-person / video / telephone]

Chaperone: [Name and role / declined after counseling / not applicable] (Include if pelvic exam performed.)

Interpreter: [Language and interpreter name/ID] (Include only if used.)

Surgical Context

[Procedure name and approach; surgery date and current postoperative day/week; primary indication; operating surgeon; notable perioperative or interval events if any] (Keep to one short paragraph.)

Chief Concern

[Reason for visit stated concisely]

Subjective

[Interval postoperative history] (Narrative paragraph covering: overall recovery trajectory; pain and analgesic use; vaginal bleeding or discharge; bowel and bladder function; diet tolerance; mobility and activity; fever or systemic symptoms; wound concerns; interval events such as ED visits or complications. For telehealth, clearly attribute all information as patient-reported. Include medication reconciliation only if changes made or adherence issues identified.)

Objective

Vitals: [Vital signs as available] (If telephone visit: No vitals obtained—telephone encounter.)

Exam: [Focused exam findings relevant to procedure and presenting concerns] (Include general appearance; abdomen; incisions/wounds with approximation, erythema, drainage, tenderness; pelvic exam if performed—cuff status, granulation, discharge; other systems as indicated. For telehealth, distinguish directly visualized from patient-reported; state explicitly if an area was not visualized.)

Data Reviewed: [Relevant labs, imaging, or pathology with dates and key findings] (Include only items actually reviewed at this visit; omit if none.)

Assessment & Plan

[Synthesis statement] (Briefly state whether recovery is progressing as expected or complicated; note key factors such as pain control, wound/cuff healing, and any active concerns.)

[Problem 1]: [Postoperative recovery status or active issue]

[Assessment and plan for this problem] (Include relevant items: wound/cuff management and local care; pathology results with documentation that findings were reviewed, discussed, and next steps communicated; medication adjustments; activity guidance with patient-specific restrictions; diagnostics or referrals ordered; follow-up timing and purpose. If pathology pending, state how results will be communicated.)

[Problem 2]: [Additional diagnosis or issue]

[Plan items as relevant] (Include only if additional problems addressed; omit section if not applicable.)

(Order problems by clinical priority. Omit non-applicable content rather than leaving placeholders.)

Return Precautions

• Fever or chills
• Worsening or uncontrolled pain
• Heavy vaginal bleeding (soaking a pad per hour) or large clots
• Wound infection signs: increasing redness, warmth, purulent drainage, or separation
• Urinary retention or severe dysuria
• Persistent vomiting, abdominal distension, or inability to pass gas/stool
• Chest pain, shortness of breath, or unilateral leg swelling/pain
• [After-hours contact instructions]