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Postoperative Follow-Up (Orthopedic Surgery) — Template & Example
Postoperative Follow-Up (Orthopedic Surgery)
Last updated: Nov 2025
Ortho Post-Op Follow-Up that’s HIPAA-compliant: capture the visit or upload audio, generate a structured note (interval history → wound → exam → plan), then auto-fill your EHR via the Nudge Chrome extension (edit-before-save).
Who this helps
Orthopedic surgeons & sports-medicine physicians
APPs (PAs/NPs) running post-op clinics
Multi-site teams standardizing phase-based rehab documentation
What you get
Structured Procedure & Date, Chief Complaint/Reason, Interval History, Wound/Incision, MSK Exam, Imaging/Studies, Complications/Red Flags, Assessment, Plan, Work/Activity Clearance, Follow-Up
Optional PROs (ASES, KOOS/HOOS, QuickDASH), PT milestones, return-to-work/sport tracking
Team-wide formatting controls (bullets/paragraphs) + redaction; carry-forward across visits
How it works with your EHR
Capture or upload in Nudge → draft appears.
Verify wound status, ROM/strength, and rehab phase.
In your EHR, open a new note and launch Nudge.
Select patient + note type → confirm mapping (Interval History, Wound, Exam, Imaging, Assessment, Plan) → save & sign.
No IT project required.
How to write an Ortho Post-Op Follow-Up note
Procedure & Date: surgery type + laterality + date.
Reason/Timing: e.g., “2-week wound check,” “6-week phase II rehab.”
Interval History: pain (0–10), sleep, analgesics, PT adherence, devices.
Wound/Incision: appearance, drainage, erythema, staples/sutures status.
MSK Exam: ROM (active/passive), strength (0–5), swelling/effusion, tenderness, gait; neurovascular.
Imaging/Studies: if obtained; key findings.
Complications/Red Flags: DVT/PE symptoms, fever, wound issues.
Assessment: healing trajectory, rehab phase, concerns.
Plan: PT phase & milestones, meds (analgesia, anticoag), wound care, restrictions (WB status, lifting), letters/clearance.
Follow-Up: exact interval + sooner-return triggers.
Quick examples
2 weeks post TKA: wound benign, ROM 0–90°, DVT ppx continuing; advance to phase II PT; f/u 4 weeks.
6 weeks post RCR: sling complete; begin active ROM and light isometrics; avoid overhead load >5–8 lb; f/u 6 weeks.
Full Sample Note — Postoperative Follow-Up (Orthopedic Surgery)
Example only; not medical advice.
Patient: [Name], 61F
Chief Complaint: 6-week follow-up after right rotator cuff repair
HPI / SUBJECTIVE:
Patient is now 6 weeks post right rotator cuff repair. She reports continued improvement with pain rated 1–2/10, significantly better than preoperatively. Sleeping more comfortably without nocturnal awakening. She completed the prescribed sling protocol and has been compliant with physical therapy. Denies wound issues, drainage, erythema, fever, or chills. Functionally, she is still cautious with overhead activities but denies catching, locking, or mechanical symptoms. No neurologic complaints.
OBJECTIVE:
PHYSICAL EXAM:
Incision: Well-healed, no erythema, drainage, or keloid formation.
Shoulder (Right): Passive forward flexion 140°, abduction 120°. Active scaption to 100° without hiking. External rotation at side 30°. Rotator cuff strength improving at 4/5 with mild pain inhibition. No crepitus.
Neurovascular: Intact distally.
DIAGNOSTICS:
No new imaging obtained today; clinical course and exam are reassuring.
PT reports reviewed in EHR confirming appropriate progression.
ASSESSMENT & PLAN:
This is a 61-year-old woman 6 weeks post right rotator cuff repair who is demonstrating appropriate healing trajectory. Exam shows satisfactory passive and early active ROM with no complications at the incision site. Rotator cuff strength is returning as expected.
Post-Operative Rotator Cuff Repair (Right Shoulder, 6 Weeks)
Continue physical therapy: advance to active ROM and begin light isometric strengthening this week.
Activity restrictions: no lifting >5–8 lb; avoid sudden abduction/external rotation.
At 10–12 weeks: if ROM milestones achieved, transition to progressive strengthening phase.
Education: reviewed expected recovery course and realistic timeline for return to sport or heavy work (generally 4–6 months). Discussed importance of avoiding premature overhead loading to reduce re-tear risk.
Hypertension
Remains stable on amlodipine. Continue current regimen.
Monitor BP at home; follow with PCP for chronic management.
FOLLOW UP:
Return in 6 weeks to reassess ROM, strength progression, and readiness for more advanced activities. Call sooner for new weakness, recurrent night pain, wound changes, or mechanical catching.
DIAGNOSES:
Z47.89 — Encounter for orthopedic aftercare following surgery
M75.121 — Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic (post-repair)
I10 — Essential (primary) hypertension
Results (2025)
Post-op follow-up notes ready in < 60–90 seconds after capture.
Teams report 4–6 hrs/week saved and cleaner PT handoffs.
FAQs
Can we set rehab phase gates and auto-advance rules?
Yes. Define milestones (e.g., pain <3/10, ER ≥45°) and surface them in the Plan.
Can I standardize wound documentation and staple/suture timelines?
Yes. Add org defaults (e.g., remove staples at 10–14 days if wound benign).
How do you handle return-to-work/sport letters?
Generate templated letters with lifting limits, motion restrictions, and re-eval date.
Shanice
Author, Nudge AI
