Postoperative Surveillance Visit Note (Carotid/EVAR/Bypass)

Date: [date of visit]

Patient: [patient name and identifier]

Provider: [clinician name and credentials]

Index Procedure: [procedure name (CEA/CAS, EVAR, lower extremity bypass), laterality if applicable, date performed]

Time Since Procedure: [e.g., ~X months postop]

Study Under Review: [modality and date of current surveillance study]

Patency/Integrity Status: [one-line status anchored to imaging: e.g., patent without significant stenosis / % stenosis range / endoleak type / graft patency] (Complete after Imaging Review)

Imaging Trend: [improved / stable / worsened] vs [prior study date]

Next Surveillance Due: [modality and interval or target month/year] (Complete in Plan; keep here for quick reference)

Reason for Visit

[One-line surveillance purpose] (State if routine postoperative surveillance with imaging review or symptom-prompted evaluation. Use brief patient quotes only for salient new symptoms.)

Interval History

[Interval events since last vascular visit] (Hospitalizations, ED visits, or reinterventions; state "none" if explicitly denied.)

[Procedure-specific symptom screen] (Carotid: TIA/stroke symptoms, amaurosis, focal neurologic changes. EVAR: abdominal/back/flank pain, limb ischemia. Bypass: claudication distance, rest pain, wound healing. Document presence/absence.)

[Medication adherence and risk factors] (Antiplatelet and statin adherence; current smoking status.)

[Imaging completion status] (If surveillance study not completed or report unavailable, state what is missing and plan to obtain it.)

Exam

Vitals: [BP, HR, and other relevant vitals]

Focused Exam: [pertinent findings tailored to procedure] (Carotid: neuro and neck. EVAR: abdomen, groins, pulses. Bypass: pulse exam, limb perfusion, wounds. Include laterality.)

(For telehealth: document what was assessed visually or by patient report, what could not be assessed, and whether in-person follow-up is needed.)

Imaging Review

Current Study: [date, modality, key numeric findings] (Duplex: PSV/EDV at key segments. EVAR: sac diameter, endoleak presence/type, limb patency.)

Comparison: [prior study date and key findings]; [improved / stable / worsened]

Interpretation: [report reviewed only / images independently reviewed] (Summarize patency/stenosis status or endoleak findings. Anchor conclusions to objective data. If imaging missing or non-diagnostic, state implications and plan.)

Assessment

[Problem 1]: Postoperative status after [CEA/CAS / EVAR / lower extremity bypass]

[Current patency/integrity determination and trend with 1–3 sentence rationale tied to Imaging Review. State symptom status (asymptomatic vs symptomatic). Note any complications or findings warranting escalation.]

[Additional Problems] (Include only if other vascular issues were explicitly discussed; provide brief rationale.)

Plan

• Next Surveillance: [modality: duplex / CTA / MRA / ABI], [interval: e.g., 6 months / annual], [target date/month]. [ordered today / patient to schedule]. (Include earlier reassessment triggers if applicable.)
• Medications: [continue / initiate / adjust antiplatelet and statin] (Tie rationale to vascular outcomes; omit if no changes.)
• Risk Reduction: [smoking cessation counseling / referral / pharmacotherapy] (Only include if current tobacco use addressed.)
• Return Precautions: [procedure-specific warnings] (Carotid: stroke/TIA symptoms. EVAR: abdominal/back pain, syncope. Bypass: acute limb ischemia, wound concerns.)
• Follow-up: [in-person / telehealth] at [timeframe] (State if earlier visit needed based on symptoms or imaging changes. Include communication to PCP/referring provider if indicated.)

(Omit procedure-specific content that does not apply. If expected information is missing, document what is missing, why, and the plan to obtain it.)