Atrial Fibrillation/Flutter Management Note

Date/Time: [Encounter date and time]

Provider: [Clinician name and credentials]

Encounter Type: [outpatient follow-up / post-procedure follow-up / telehealth]

Care Setting: [clinic / telehealth]

Chief Complaint

[One-line reason for visit] (Use patient's words when provided.)

Interval History

[Narrative since last visit] (Begin with the chief concern and reason for visit now. Include AF vs flutter classification and pattern [paroxysmal / persistent / long-standing persistent / permanent] if known; symptom burden with standardized severity [EHRA class I–IV] and functional impact; recent episodes and triggers; current rate and rhythm control tolerance including medication side effects; anticoagulation adherence and any bleeding concerns; relevant comorbidity updates such as weight change, sleep apnea therapy, alcohol use, and blood pressure control. Label patient-reported information as such. Include pertinent negatives.)

Objective

Vitals: [HR with regularity, BP, weight, O2 sat as relevant] (Note source if telehealth or home measurements.)

Exam: [Pertinent cardiovascular findings—rhythm regularity, murmurs, JVP, edema] (Add other systems only if clinically indicated.)

Rhythm Data: [Today's ECG or rhythm strip: rate, rhythm, intervals (PR, QRS, QTc)] or [Monitoring summary: AF burden, rate distribution, notable events with date/source] (Omit if not performed.)

Diagnostics: [Relevant echo findings, labs for anticoagulant dosing, TSH, other imaging as applicable with dates] (Note any critical decision data pending if applicable, e.g., creatinine for DOAC dosing.)

Assessment & Plan

[Summary statement: AF/flutter diagnosis and classification, current rhythm status with objective basis, symptom severity, and key contributing factors] (Keep to 1–2 sentences.)

Stroke Prevention: CHA₂DS₂-VASc [score]. [Anticoagulation plan: continued/initiated with agent, dose, and rationale including renal dosing; OR deferred with explicit reasoning and reassessment plan; OR alternative strategy such as LAA occlusion referral with interim plan.] [Bleeding risk factors and adherence concerns if relevant.]

Rate/Rhythm Strategy: [Current approach: rate control / rhythm control / observation] and whether goals are being met. [Medication adjustments with rationale if any.] [Cardioversion planning if applicable: anticoagulation timing, pre-procedure imaging needs, post-procedure anticoagulation plan.] [Ablation referral if applicable: indication and interim management.] (If unchanged, document "no change to current strategy" with brief reason.)

Risk Factor Modification: [Counseling or plans for weight, exercise, alcohol, sleep apnea, blood pressure as addressed today] (Omit if not addressed.)

Orders & Follow-up: [Tests ordered; medication changes with monitoring requirements; referrals placed; follow-up timing and modality; return precautions (stroke symptoms, significant bleeding, syncope)]