Send every surgical patient home with a documented, personalized recovery plan.
Healthcare template · 13 fields (9 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Post-operative instructions delivered verbally at discharge are half-forgotten by the parking lot. This form turns the discharge conversation into a structured record: the procedure performed, wound care steps, activity restrictions, prescribed medications, warning signs that warrant a call, and the follow-up date — all documented per patient.
For surgical practices, the value runs both directions: patients get a written plan they can revisit, and the practice gets documentation that instructions were provided — including the specific warning signs reviewed — which matters when complications and questions arise later.
Best practices
Complete the form with the patient present and talking through each section — the documentation is a byproduct of a better discharge conversation.
Warning signs deserve the most attention. Patients tolerate discomfort they were told to expect and panic over symptoms nobody mentioned.
List medications with times and food requirements, not just names and doses. "Take with food, 12 hours apart" prevents most callback questions.
Schedule the follow-up before discharge and record it here — patients who leave with an appointment keep it at far higher rates than patients told to call and book one.
Every field, explained
Patient Name (Name, required)
Surgery Date (Date, required)
Procedure Performed (Long text, required)
Surgeon Name (Short text, required)
Anesthesia Type Used (Single choice, required)
Post-Op Instructions Given (Multiple choice)
Wound Care Instructions (Long text, required) — Written in plain language the patient will reread at home — avoid clinical shorthand here.
Activity Restrictions (Multiple choice) — Specific beats general: "no lifting over 10 lbs for 2 weeks" outperforms "take it easy."
Prescribed Medications (Long text, required)
Follow-up Appointment Date (Date, required) — Booked before discharge, documented here.
Warning Signs Discussed (Multiple choice) — The checklist that determines whether a complication is caught on day two or day five.
Emergency Contact Number (Short text, required)
Additional Post-Op Notes (Long text)
Frequently asked questions
What should a post-operative care plan include?
Six essentials: the procedure performed, wound care instructions, activity restrictions, medications with schedules, warning signs requiring immediate contact, and the follow-up appointment. This template documents all six plus emergency contact and anesthesia details.
Is this form HIPAA compliant?
The template is HIPAA-ready: on a HIPAA-enabled FormBuilder plan, submissions containing protected health information are encrypted, access-controlled, and covered by a Business Associate Agreement.
Who fills out a post-operative care form — the patient or the provider?
The care team completes it at discharge, ideally with the patient present. Some practices then share a copy with the patient so the instructions travel home in writing.
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