Post-Operative Follow-Up Note Template
The record of a review after surgery. Used consistently it turns a series of appointments into one readable account of recovery, which is what makes a deviation obvious rather than something noticed in hindsight.
At each post-operative review, including unplanned attendances.
The template
POST-OPERATIVE FOLLOW-UP Procedure: Date of surgery: Interval since surgery: Review: planned / unplanned SUBJECTIVE Overall progress as reported by patient: Pain and analgesia requirement: Symptoms reported: Red flags specifically asked about and denied: Function and activity level: Return to work / driving / exercise: Patient's own concerns: OBJECTIVE Observations (if taken): Wound / incision: Signs of infection: Swelling, bruising, seroma, haematoma: Site-specific examination: Sensation: Drains: Sutures or staples: Photographs taken: yes / no ASSESSMENT Recovery relative to expected course: Complications identified: Differential where the course is atypical: PLAN Wound care: Analgesia adjustment: Activity advice: Garment or support: Scar management: Investigations ordered: Referral: Next review: Patient advised to make contact earlier if:
Free to use and adapt. It is a structure, not clinical or legal advice — your records remain your professional responsibility.
Completed example
The same structure filled in, so you can see the level of detail it is built for. Details are illustrative and not from a real patient.
POST-OPERATIVE FOLLOW-UP Procedure: bilateral breast augmentation, dual-plane Date of surgery: 14 March 2026 Interval: three weeks Review: planned SUBJECTIVE Reports steady improvement. Discomfort now controlled with simple analgesia only, no codeine for the past week. Describes intermittent tightness across the upper poles, worse in the evenings. Specifically denies fever, unilateral swelling, discharge and increasing unilateral pain. Resumed desk work at two weeks. Not yet returned to exercise, as advised. Own concern: whether the upper pole tightness is expected. OBJECTIVE Incisions: inframammary, healing well bilaterally, no dehiscence. No erythema, no collection, no discharge. No fluctuance. Implants symmetrical in position, no evidence of malposition or rippling. Capsule soft bilaterally, Baker grade I. Sensation intact to light touch; nipple sensation preserved bilaterally. No drains. Subcuticular sutures absorbable, no removal required. Photographs taken. ASSESSMENT Uncomplicated recovery at three weeks. Upper pole tightness consistent with expected oedema and muscle adaptation rather than early capsular contracture, and explained to the patient as such. PLAN Continue supportive garment a further three weeks. Commence scar massage now incisions are fully epithelialised. Gradual return to cardiovascular exercise from week four; no upper body resistance work until week six. Review at three months with photographs. Advised to make contact earlier if unilateral swelling, fever or increasing firmness develops.
Documentation considerations
- Keep the same headings at every review. A consistent structure is what lets you see a trend across three appointments.
- Record the interval since surgery in every note. "Week three" means something; "recent surgery" does not.
- Separate patient-reported symptoms from examination findings, and record both even when they agree.
- Document the absence of red flags explicitly. A note silent on fever does not show that fever was asked about.
- Record what the patient was told to watch for and when to make contact.
Have this filled in for you
Patien listens to the encounter and returns the note in this structure. Templates are editable, so if your headings differ from these, change them once and every note follows.
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