Trauma Clinic Follow-Up Note

Trauma Clinic Follow-Up Note

(Create a concise, problem-focused follow-up note that references key discharge diagnoses/procedures rather than restating the entire hospital course. Omit sections without clinically meaningful information. Document "unable to assess" when data gaps affect safety decisions.)

Date of Service: [Date]

Provider: [Name, credentials]

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

Historian: [patient / caregiver / other] (Note if interpreter used or reliability limited.)

Chief Complaint

[One-line reason for today's visit in patient language]

Index Event Summary

[Injury date]; [Discharge date]. [Mechanism of injury]. [Key injuries and procedures with dates]. [Discharge disposition]. [High-risk items requiring tracking: anticoagulation plan; weight-bearing status; spine precautions; wound/drain plan]. (Keep concise. For subsequent visits where unchanged: "Index trauma summary reviewed; relevant changes documented below.")

Interval History

[Days/weeks since discharge]. [Primary goals for today]. [Overall trajectory: improved / stable / worsened] with [supporting facts].

• Interval events: [ED visits, readmissions, new/worsening symptoms including fever, wound changes, neurologic deficits, falls] (Document only items asked and answered; if unknown, state gap and education provided.)
• Pain and symptom control: [Pain location, intensity, functional interference, current regimen as taken, effectiveness, side effects]. (If opioids: include sedation symptoms, concurrent sedative/alcohol use, safe storage, driving counseling, taper plan.)
• Wound/device status (patient-reported): [Drainage, erythema, swelling, cast/splint tolerance, numbness/tingling].
• Functional recovery: [Mobility, assistive devices, ADL limitations, driving status].
• Follow-up compliance: [Specialty visits completed/missed, pending studies, rehab services].

(Do not infer adherence or deny red-flag symptoms unless explicitly discussed.)

Objective

Vitals: [Vital signs as relevant] (Omit or comment only if clinically meaningful.)

Exam: [Focused exam: general appearance; cardiopulmonary and neurologic exam if indicated; injury-site exam including ROM, tenderness, stability, distal neurovascular status]

Wound/Device Findings: [For each wound/incision: location, closure type, edges, drainage, infection signs. For drains: output trend, site condition, removal criteria. For casts/splints: fit, skin integrity, neurovascular status.] (Omit if none relevant.)

Data Reviewed: [Imaging, labs, outside records with key findings] (Omit if none reviewed.)

Assessment & Plan

(List problems in decreasing clinical priority. For each: state status with evidence, screen for pertinent complications, outline plan.)

[Problem 1]: [Diagnosis or injury]

[Status: improved / stable / worsened] with [supporting evidence]. [Complication screening findings]. [Diagnostics ordered/deferred]. [Therapeutics: medications, wound care, device adjustments]. [Restrictions with duration and reassessment date]. [Education provided]. [Follow-up timing].

[Problem 2]: [Diagnosis or injury]

(Include additional problems as needed using same format.)

Pain Regimen: [Multimodal plan]. [If opioids: indication, drug, dose, quantity, taper plan; adverse-effect prophylaxis; safety counseling re: sedation, concurrent substances, storage, driving]. (Include only if pain management addressed.)

Functional Status and Restrictions: [Current functional level]. [Weight-bearing status; lifting limits; ROM restrictions; driving/work status with rationale]. [Duration and reassessment date]. (Keep specific and measurable.)

Procedures Performed Today: [Procedure name, indication, consent, site verification, technique, findings, tolerance, post-procedure instructions]. (Include only if procedure occurred.)

Care Coordination: [Specialty referrals, PT/OT orders, DME needs, home health, social work as applicable].

Return Precautions: [Fever with wound changes; new neurologic deficits; uncontrolled pain; rapid swelling; other injury-specific red flags].