Phone Consultation Progress Note
Created by
Jason Wilson
Specialty
Orthopaedic Surgeon
Last edited
10/20/2026
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About this template
A reusable template for documenting orthopaedic updates discussed by telephone. It covers relevant history, current treatment and response, specialty progress, and follow-up planning.
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Phone Consultation Progress Note
Date: 14/05/2024
Time: 14:15 - 14:30 MST
Contact: Sarah Jenkins, RN (Home Care Wound Clinic)
Regarding: Robert Vance, 62-year-old male (ULI: 482-910-384)
Background
- Laparoscopic sigmoid colectomy for diverticulitis on 28/04/2024.
- Presented to Rockyview General Hospital ED on 08/05/2024 for superficial surgical site infection (SSI) at the Pfannenstiel extraction site; staples removed and wound opened.
- Low threshold for readmission if signs of systemic sepsis, fascial dehiscence, or deep space abscess develop.
Current Status
- Managed as an outpatient (not currently admitted).
- Receiving daily home care visits for normal saline irrigation and Aquacel Ag ribbon packing; completing a 7-day course of cephalexin (Keflex) 500 mg PO QID.
- Responding well to therapy; afebrile, tolerating regular diet, normal bowel function, and pain controlled with paracetamol (Tylenol) 1,000 mg PO Q6H PRN.
General Surgery Progress
- Negative pressure wound therapy (NPWT) considered but deferred given rapid improvement with standard wet-to-dry/alginate packing; wound depth decreased from 3.5 cm to 2.0 cm over the past 5 days.
- Independent ambulation inside the home without gait aids; avoiding heavy lifting > 5 kg as instructed.
- Extraction site wound base is 100 % red granulation tissue with minimal serosanguinous exudate; surrounding erythema has completely resolved and fascial layer remains intact on probing.
- CT abdomen/pelvis from ED visit on 08/05/2024 confirmed a 3 x 2 cm superficial subcutaneous fluid collection with no intra-abdominal collection or anastomotic leak.
Plan
- In-person review in the General Surgery Outpatient Clinic in 2 weeks (28/05/2024); continue daily home care packing changes until seen.
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