Date:
Patient:
MRN:
Clinician: (Board-certified Plastic Surgeon, Gynecologist)
Reason for Visit:
Post-operative follow-up for female genital cosmetic surgery (FGCS)
(Specify procedure): Labiaplasty, Vaginoplasty, Monsplasty, etc.
Evaluation of healing and wound status
Discussion of post-operative care and recovery
History of Present Illness:
Briefly describe the specific FGCS procedure performed.
Document the patient’s preoperative concerns and desired outcomes.
Past Medical History:
Include any relevant past medical conditions that may affect healing or surgery (e.g., bleeding disorders, diabetes).
History of prior surgeries (pelvic or otherwise).
Medications:
List current medications, particularly those that could affect bleeding or wound healing (blood thinners, certain herbal supplements).
Allergies:
Document any known allergies to medications, anesthesia, or surgical materials.
Social History:
Smoking history (smoking can impede healing).
Sexual history (important for post-operative activity restrictions).
Physical Exam:
General: Vital signs (temperature, blood pressure)
Pelvic: Visual inspection of the surgical site to assess healing, swelling, and signs of infection (redness, drainage)
(Optional) Digital exam – May be performed to assess vaginal tightness or tenderness (depending on procedure).
Assessment:
Describe the healing progress of the surgical site.
Evaluate for any post-operative complications (infection, bleeding, hematoma).
Assess pain level and patient’s comfort.
Plan:
Outline post-operative care instructions:
Wound care (cleaning, dressing changes)
Pain management with medication (if needed)
Activity restrictions (sexual activity, exercise)
Showering or bathing instructions
Follow-up appointment schedule
Education:
Document any education provided to the patient regarding:
Expected healing process and potential discomfort
Warning signs of infection (fever, redness, increased pain)
Importance of adhering to activity restrictions
Gradual return to sexual activity (if applicable)
Resources for emotional support (if needed)
Notes:
Include any additional relevant information not covered above, such as the patient’s emotional well-being and any concerns they may have.
Document the patient’s understanding of post-operative instructions.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a board-certified plastic surgeon or gynecologist for female genital cosmetic surgery. This template does not constitute medical advice.