Urology Postoperative Follow-Up Note

Date of Service: [Date of service]

Provider: [Provider name, credentials]

Location/Encounter Type: [in-person clinic / telehealth / inpatient follow-up]

Procedure: [Procedure name with laterality]

Date of Surgery: [Date]

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

Operating Surgeon: [Name] (Only include if different from current provider.)

Indication: [Surgical indication]

Pathology Status: [final / pending / not applicable]

Chief Complaint

[Single-line anchor to surgery and current purpose of visit] (Include POD/POW and specify whether routine follow-up or problem-focused concern.)

Interval History

[Narrative postoperative course since surgery or last visit] (Begin with overall trajectory: improving/stable/worsening/new symptoms. Address: pain control and analgesic use; urinary function and voiding status; device-related symptoms if catheter/stent/drain present; infection/complication screening; GI recovery; any post-discharge events such as ED visits or calls. End with explicit complications statement: "No complications identified" or description of each complication with onset and status. For items not assessable, state what was not evaluated and why.)

Objective

Vitals: [Vital signs summary] (If telehealth, state "not obtained.")

Exam: [Focused postoperative exam] (Include general appearance, abdomen/flanks, incision/wound status, GU exam as indicated. For sensitive exams, document chaperone offer and response.)

Data Reviewed: [Pertinent labs, imaging, pathology, operative/discharge reports] (Summarize key dated results only.)

Assessment & Plan

[Postoperative recovery status statement] (One line: course appropriate for POD with expected symptoms, or complicated with current trend.)

[Problem]: [Diagnosis or postoperative issue]

[Assessment and plan] (Concise rationale referencing today's findings. Include specific management steps, orders placed today, and follow-up for this problem. Repeat this section for each active problem.)

Device Management

(Include if catheter, stent, drain, or implant present.)

[Device type, laterality, current status/function, symptoms]

• Removal Plan: [Target date/timeframe, prerequisites, location]
• Interim Management: [Symptom management, troubleshooting, when to call]
• Stent Tracking: [Tracking method, responsible party, due date] (Required for ureteral stents to prevent retention.)

(If in-office procedure performed today: [Procedure name] — [Indication, technique, findings, tolerance, complications])

Pathology Review

(Include when final pathology available or pending.)

[Key findings] (Document that results were communicated to patient.)

• Implications: [Stage, risk, interpretation]
• Plan: [Surveillance schedule, referrals, adjuvant workup]

(If pending: [Expected timeframe and who will communicate results])

Activity Restrictions

(Include when applicable.)

• [Lifting limit, driving, bathing, sexual activity, return-to-work timing]

Follow-up and Safety Net

• Next visit: [Timeframe and modality]
• Pre-visit: [Labs/imaging to obtain beforehand]
• Return precautions: [Red-flag symptoms and where to seek care]
• Pending items: [Results, authorizations, device removals to track]