Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Admitting Physician:
Date of Discharge:
Discharge Diagnosis:
Attending Physician (for this visit):
Reason for Visit
Briefly state the primary reason for the patient’s follow-up visit.
This could be a scheduled appointment to monitor recovery, address specific post-discharge concerns, or remove stitches/drains (if applicable).
History Since Discharge
Inquire about the patient’s overall well-being and recovery progress since discharge.
Gather details on:
Adherence to discharge medications and instructions.
Presence of any new or worsening symptoms.
Progress in wound healing or other post-surgical concerns.
Ability to perform daily activities and any limitations.
Physical Examination
Perform a focused physical examination relevant to the patient’s discharge diagnosis and post-operative status (if applicable).
Document any pertinent findings.
Assessment and Plan
Based on the patient’s reported progress and your examination findings, assess their current health status.
Formulate a plan for ongoing care, including:
Adjustments to medication regimen as needed.
Referral to specialists or physical therapy (if applicable).
Modification of activity restrictions or recommendations.
Scheduling of follow-up appointments.
Patient Education
Address any questions or concerns the patient may have about their recovery or ongoing care.
Provide additional education or resources as needed, such as:
Management of specific symptoms.
Wound care techniques.
Lifestyle modifications to support recovery.
Warning signs and symptoms to prompt seeking medical attention.
Prognosis
Provide a brief update on the patient’s overall prognosis, considering their progress and any adjustments to the treatment plan.
Note: This is a general template, and additional details may be necessary depending on the specific patient’s situation and the reason for their visit. Remember to document any communication with other healthcare providers involved in the patient’s care.