Ayurveda Outpatient Progress Note

Date/Time: [Encounter date and time]   Patient: [Full name]   DOB: [MM/DD/YYYY]   Visit Type: [new / established]   Provider: [Name, credentials]   Location: [Clinic location / telehealth site]   Source of History: [Patient / family / records; note reliability concerns]

Subjective

Chief Concern: [Primary reason for visit in one line; brief patient quote if helpful] (If multiple concerns, list in priority order.)

History of Present Illness: [Narrative of symptom timeline and evolution, quality/severity/frequency, aggravating and relieving factors, associated symptoms, pertinent negatives relevant to red flags, functional impact, and prior self-care including any past Ayurveda approaches tried] (For established patients, begin with interval history: response to prior plan, adherence, new symptoms/diagnoses, and medication/supplement changes since last visit. Include patient goals and preferences for this visit. When relevant, include digestion, appetite, elimination patterns, sleep quality, energy, stress, and temperature tolerance.)

Relevant Background: [Pertinent past medical/surgical history, family history, and social/lifestyle factors relevant to current concerns; reproductive status if relevant to herbal recommendations] (For established patients, document only updates.)

Medications and Supplements: [All current prescriptions, OTC products, vitamins, herbals, and Ayurveda formulas with name, dose, frequency, and adherence] (For Ayurveda preparations, specify herbal-only vs mineral/metal-containing and document source/brand when known.)

Allergies: [Medication, food, and supplement allergens with reaction types; if none, state "No known allergies."]

Objective

Vitals: [BP, HR, RR, Temp, SpO2, Weight as obtained] (If not collected, state reason.)

Physical Exam: [General appearance and focused exam findings pertinent to presenting concerns] (Document only findings actually assessed. Include pertinent positives and negatives. Do not auto-populate normal findings.)

Ayurveda Observations: [Raw findings from tradition-specific assessments performed: pulse (nadi) qualities with method, tongue characteristics, skin/hair/nail observations, and other relevant qualities] (Record observations separately from interpretive conclusions.)

Data Reviewed: [Relevant labs, imaging, external records, and patient-reported home monitoring with dates and key findings]

Procedures Performed: [In-office therapy provided: indication, consent obtained, brief description of technique, patient tolerance, and any complications] (Omit section if none.)

Assessment

Working Impression: [Problem list ordered by priority; for each problem, provide diagnosis or symptom-based impression with brief status statement; include differential diagnoses when clinically relevant; note red flags assessed and their status]

Ayurveda Clinical Assessment: (Clearly labeled as clinician interpretation.)

• Prakṛti: [Assessed constitution; method used; confidence level]
• Vikṛti: [Doṣa involvement; agni status; āma indicators] (Link interpretations to documented findings.)
• Nidāna: [Contributing dietary, lifestyle, environmental, seasonal, or psychosocial factors]

Safety Considerations: [Contraindications relevant to proposed interventions; pregnancy/lactation status if herbs considered; potential interactions; need for referral or urgent evaluation if identified]

Plan

(Organize by problem when multiple issues are addressed.)

Goals: [Patient-centered, measurable goals with timeframe]

Diet and Lifestyle: [Specific recommendations with timing/duration: meal timing, food modifications, sleep schedule, activity, daily routine changes] (Avoid generic advice.)

Herbs and Supplements: [Itemized recommendations: name, dose, route, frequency, timing, duration; precautions and what to stop for; interaction concerns to monitor] (For mineral/metal-containing preparations, document counseling on risks and monitoring plan.)

Other Interventions: [Mind-body practices with frequency and modifications; in-clinic therapies with schedule; conventional medications to continue or coordinate]

Education and Consent: [Risks, benefits, and alternatives discussed; patient understanding and agreement documented]

Referrals: [Specialty, reason, and specific questions to address] (Omit if none.)

Follow-up: [Timeframe for next visit; what to report sooner and how to contact clinic]

Time-Based Billing: [Total clinician time on date of encounter] (Include only if documenting for time-based billing.)

Signature: [Provider name, credentials]   Date/Time Signed: [MM/DD/YYYY HH:MM]