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Postoperative Note Procedure Context - Procedure performed, date, surgeon/service, and setting (outpatient/inpatient). - Key operative findings and immediate post-op disposition as known. Interval History - Pain control, oral intake, bowel/bladder function, fever, chills, wound drainage, bleeding, dyspnea, calf pain, and other concerns. - Adherence to activity restrictions and medications (antibiotics, anticoagulation, analgesia). Exam - Vital signs and general appearance. - Surgical site/wound/drain examination; neurovascular check of relevant limb if applicable. - Focused systemic exam as indicated. Data Reviewed - Post-op labs, imaging, pathology prelim/final, and culture results as available. Assessment - Expected recovery vs concern for complication (infection, hematoma, VTE, ileus, dehiscence, etc.). - Pain control adequacy and wound healing stage. Plan - Wound care, drain management, suture/staple removal timing. - Medications (continue/stop antibiotics, VTE prophylaxis, analgesia taper). - Activity, lifting, work/school, driving, and rehab/PT as applicable. - Red-flag return precautions and next follow-up.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Centers procedure details and interval recovery instead of rewriting the op report.
- Prompts wound, pain, VTE, infection, and red-flag review.
- Supports early post-op clinic and inpatient post-op progress notes.
- Patient instructions and activity restrictions land in a consistent block.
- 1Postoperative clinic follow-up visits
- 2Early inpatient post-op progress notes
- 3Wound and drain checks after procedures
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Procedure Context POD #10 after open inguinal hernia repair (right), Dr. Cho, ambulatory surgery 7/16/2026. Mesh repair; discharged same day. Interval Pain well controlled on acetaminophen; stopped oxycodone day 4. Ambulating; no fever. Mild bruise at incision; scant clear drainage day 2–3, now dry. No calf pain, dyspnea, or wound erythema. Exam Afebrile, HR 72, BP 124/76. Incision clean, dry, intact; no fluctuance or spreading erythema. Scrotum without significant hematoma. Abdomen soft, non-peritoneal. Assessment Uncomplicated post-op recovery after right inguinal hernia repair; wound healing appropriately. Plan Continue dry dressing PRN; shower OK; no soaking 2 more weeks. Activity: walking encouraged; no lifting >10 lb for 4 more weeks. Follow up 6 weeks or sooner for fever, increasing redness, wound opening, or severe pain. Return precautions reviewed; patient verbalized understanding.
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