When to use this post-op template
Use it for any check after surgery or endodontic treatment: suture removal, a 1-week extraction check, an implant healing visit, or an unscheduled visit for pain. Post-op visits are short and often go undocumented or get a one-word note like "healing." If a complication comes up later, the follow-up note is what shows you saw it and acted on it.
What a follow-up note should include
- The original procedure, site, and how long ago it was done.
- The patient's report: pain trend, medications, whether they followed instructions.
- The site findings, including sutures, exposed bone, and signs of infection.
- Sensation after any procedure near a nerve.
- What you did and the next step, even if that's releasing the patient.
Example post-op note
Patient seen for a post-operative follow-up, 2–3 days after surgical extraction at #17. Patient reports pain increasing and a bad taste. Pain level 7–10/10. Taking OTC analgesics as needed. Healing: alveolar osteitis (dry socket); exposed bone. Sensation normal. Treatment today: site irrigated, dry socket dressing placed, instructions reinforced. Assessment: complication managed, improving. Next step: re-check in 2–3 days.