Orthopedics — Postoperative Follow-Up Template

Visit Information

Date: [Date]
Postoperative week/month: [X] weeks / [X] months
Last visit: [Date]

Surgical Information

Procedure: [Procedure name]
Date of surgery: [Date]
Surgeon: [Name]
Side: Right / Left
Surgical facility: [Hospital/ASC]
Anesthesia: General / Regional / [Other]
Brief operative findings: [Key findings]

Interval History

Overall recovery: As expected / Better / Slower
Patient satisfaction: Satisfied / Neutral / Dissatisfied — Reason: [If applicable]

Pain Assessment

Current pain level: [X]/10
Pain trend: Improving / Stable / Worsening
Pain character: Incisional / Deep / Referred / [Other]
Breakthrough pain episodes: None / [Frequency, triggers]
Current pain medications:

• [Medication, dose, frequency, quantity remaining]
• Need refill: Yes / No
• Attempting to wean: Yes / No

Night pain: None / Occasional / Frequent — Awakens from sleep: Yes / No

Functional Status

Weight-bearing status:

• Prescribed: NWB / TTWB / PWB / WBAT / FWB
• Actual compliance: Full / Partial / Non-compliant

Brace/splint/sling:

• Prescribed: [Type, wear schedule]
• Compliance: Full / Partial / Not wearing

Ambulatory status:

• Assistive device: None / Cane / Crutches / Walker / Wheelchair
• Distance: [Feet/blocks]
• Stairs: Unable / With rail / Independent

ADLs:

• Dressing: Independent / Needs assistance
• Bathing: Independent / Needs assistance
• Driving: Not cleared / Cleared / Resumed [date]

Sleep: Normal / Disrupted by: [Pain, positioning, etc.]

Physical Therapy Progress

Therapy attending: Yes / No

• Facility: [Name]
• Frequency: [X] times/week
• Sessions completed: [X]

Current PT focus: [ROM, strengthening, gait training, etc.]
Home exercise compliance: Excellent / Good / Fair / Poor
Range of motion progress:

• [Joint]: [Current degrees] (Goal: [X]°)
• [Joint]: [Current degrees] (Goal: [X]°)

Strength progress: [Improving / Plateau / Decline]
PT concerns: None / [Issues to address]

Complications Screening

DVT/PE symptoms:

• Calf pain/swelling: Yes / No
• Dyspnea/chest pain: Yes / No
• On anticoagulation: Yes / No — [Agent, duration]

Infection signs:

• Fever: Yes / No
• Wound drainage: Yes / No — [Type if yes]
• Increasing redness: Yes / No
• New onset wound pain: Yes / No

Other complications:

• Stiffness concerns: Yes / No
• Hardware issues: Yes / No
• Nerve symptoms: Yes / No — [Details]
• Compartment concerns: N/A / None / [If applicable]

Physical Examination

General: Well-appearing / [Concerns]
Ambulatory status observed: [Gait description, assistive device]

Surgical Site

Incision:

• Location(s): [Anatomic location]
• Healing: Well-healed / Healing / [Concerns]
• Approximation: Good / Dehiscence [location, extent]
• Drainage: None / Serous / Serosanguinous / Purulent
• Erythema: None / Mild / Significant
• Warmth: None / Present
• Induration: None / Present
• Sutures/staples: Removed / In place / Dissolving

Swelling: None / Mild / Moderate / Severe

• Compared to last visit: Improved / Same / Worse

Ecchymosis: None / Resolving / [New/persistent areas]

Range of Motion

[Joint]: Active [X]° / Passive [X]°

• Flexion: [X]°
• Extension: [X]° / Extension lag: [X]°
• [Other relevant motions]: [X]°

Compared to prior visit: Improved / Same / Decreased

Strength

[Relevant muscle groups]: [X]/5
Compared to prior visit: Improved / Same / Decreased

Stability

Ligament/repair integrity: Intact / [Concerns]
[Specific stability tests if applicable]: [Results]

Neurovascular

Sensation: Intact / [Deficits]
Motor: Intact / [Deficits]
Pulses: Palpable / Dopplerable / [Concerns]
Capillary refill: <2 seconds / Delayed

Imaging Review

X-rays obtained: Yes / No
Date: [Date]
Views: [AP, lateral, etc.]
Findings:

• Alignment: [Maintained, changed]
• Hardware: [Intact, position, concerns]
• Healing: [Callus formation, bone healing status]
• Joint space: [If applicable]
• Other: [Findings]

Compared to prior: Improved / Stable / [Concerns]
Advanced imaging: N/A / Ordered / [Findings if available]

Assessment

[Weeks/months] status post [procedure] — [Side]
Recovery status: On track / Ahead of schedule / Behind schedule

• [Specific progress or concerns]

Plan

Weight-Bearing/Activity

Current: [NWB / TTWB / PWB / WBAT / FWB]
Advance to: [Next phase] starting [Date/criteria]

Immobilization

Brace/splint/sling:

• Continue: [Type, schedule]
• Discontinue: [Date]
• Transition to: [If applicable]

Physical Therapy

• Continue current program / Advance protocol
• New focus: [ROM, strengthening, sport-specific, etc.]
• Frequency: [X] times/week
• Duration: [X] more weeks
• Home exercises: [Specific additions]

Medications

Pain management:

• Continue: [Medications]
• Wean: [Schedule]
• Discontinue: [Which ones]
• Refill: [If needed]

Anticoagulation:

• Continue: [Agent] for [X] more [days/weeks]
• Discontinue: [Date]

Activity Restrictions

Work:

• Remain off work until: [Date/milestone]
• Return light duty: [Date] with restrictions: [X]
• Return full duty: [Date/criteria]

Driving:

• Cleared: Yes / No
• Criteria: [Off narcotics, functional ROM, etc.]

Sports/recreation:

• Current restrictions: [List]
• Cleared for: [Activities]
• Timeline for return to sport: [X weeks/months]

Anticipated Milestones

[Next visit]:

• Expected ROM: [X]°
• Expected strength: [X]
• Expected functional level: [X]
• Anticipated clearance: [Activities]

Follow-up

Return: [X] weeks

• Purpose: [Wound check, X-ray, progress assessment]
• X-rays: [Needed at next visit]

Sooner if:

• Signs of infection (fever, worsening drainage, increasing redness)
• DVT/PE symptoms
• Significant increase in pain
• Loss of function
• Concerns about healing

Communication

Report to: [PCP, referring physician, employer if work-related]
PT updated: Yes / Prescription provided

Patient Education

Expected recovery timeline, activity progression, wound care (if needed), signs of complications, medication management, importance of PT compliance, return precautions.