Headings
Procedure summary · Healing progress · Wound check · Sutures · Swelling and bruising · Patient concerns · Instructions given · Next review
When to use it
Use this at the 5 to 10 day visit, when sutures come out and healing can be judged properly. It records what the client is worried about as well as what you find. It follows the day one note and sets up the longer recovery reviews.
Example
Fictional example
Procedure summary
G.F., 31F. Open rhinoplasty 7 days ago. Dorsal hump reduction and tip refinement.
Healing progress
Breathing well through both sides. Off prescription pain medicine since day 3.
Wound check
Columellar incision well healed. No redness or discharge.
Sutures
Columellar sutures removed. External splint removed. Skin intact beneath.
Swelling and bruising
Moderate tip swelling. Yellow fading bruises under both eyes.
Patient concerns
Worried the tip looks wide. Explained tip swelling lasts months and settles slowly.
Instructions given
No glasses on the bridge for 4 weeks. Saline rinses twice daily. No contact sports for 6 weeks.
Next review
Clinic in 6 weeks.