The plastic-surgery document checklist
- Discharge summary: diagnosis, admission/discharge dates and condition at discharge.
- Operation note: procedure, surgeon, assistants, findings and relevant technique details.
- Anaesthesia record: anaesthesia type, anaesthetist and significant events.
- Implant or device card: manufacturer, model, size, lot/serial and implantation site.
- Medication and prescription list: generic names, dose, frequency, duration and allergies.
- Laboratory and imaging results: pre- and post-operative tests and original image files where relevant.
- Pathology report: for tissue sent for histology, if applicable.
- Wound and drain instructions: dressing, showering, drain removal and support garments.
- Activity restrictions: lifting, driving, sleeping position, work and exercise.
- Fit-to-fly advice: individual clearance, timing, mobility and airline documentation.
- Follow-up schedule: local and remote reviews with named clinical contacts.
- Emergency escalation plan: symptoms, 24-hour contact and nearest appropriate facility.
- Itemised invoice and payment proof: surgeon, anaesthesia, hospital, devices and package services.
- Consent and revision terms: signed consent plus written guarantee/complaint terms.
Which record helps with which problem?
Check the handover before checkout
- Open every PDF, scan link and image file.
- Check spelling of your name, procedure and dates.
- Ask for generic medicine names and an English summary.
- Save copies offline and share them with a trusted person.
- Separate the clinical emergency contact from the sales contact.
Implant and device identifiers matter
For breast implants or other implanted devices, keep the patient device card or equivalent record with manufacturer, product and serial or lot information. The FDA notes the importance of patient device cards in breast implant communication. These details help identify the device if safety information, imaging or revision is later needed.
Dental versus plastic-surgery records
The existing 12 Documents After Dental Treatment guide covers CBCT, tooth numbers, implant components and laboratory certificates. This checklist covers surgical admission, anaesthesia, devices, wounds and pathology.
Also review plastic surgery coordination and safety and aftercare.
Frequently asked questions
Do I need the operation note or only a discharge summary?
Ask for both. The discharge summary gives the overview; the operation note records what was performed and relevant findings.
What should a breast implant card include?
Manufacturer, model or product, size, serial or lot identifiers, side/site and implantation date where available.
Are WhatsApp photographs enough?
No. Request original reports and image files in usable formats, and keep the message history only as supplementary evidence.
Should records be translated into English?
Keep the originals and request an English clinical summary. Formal claims may require a certified translation.
Can a UK doctor refuse routine follow-up?
A clinician must assess what care they can safely provide. Complete records help but do not oblige them to assume routine private aftercare.
When should I request the documents?
Agree the list before treatment and check completeness before leaving the facility or hotel, while corrections are easier.
Sources and further reading
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