Chronic Disease Follow-Up Note (Adult, Internal Medicine)

Date/Time: [Encounter date and time]
Patient: [Patient name and identifier]
Provider: [Clinician name and credentials]
Visit Type: [in-person / telehealth: video / telehealth: phone]
Location: [Clinic site or telehealth location]

Reason for Visit

[Chief complaint or follow-up statement] (Prefer patient's own words when symptom-driven; otherwise list conditions being followed or specific concern. If unclear, document "Chronic disease management per scheduled follow-up.")

Interval History

[Narrative of changes since last visit, anchored to prior visit date] (Include intercurrent events, specialist recommendations, condition-specific updates with home monitoring summaries, medication adherence and tolerance, barriers to care, and patient-stated goals or concerns. Keep problem-focused. If key information was not obtained, state the gap and plan to obtain. Do not infer adherence or symptom status without explicit report or corroborating data.)

Objective

Vitals: [BP, HR, weight/BMI, others as relevant with dates]

Exam: [Targeted findings pertinent to conditions managed today; include complication screening performed] (If exam not performed or limited, state briefly.)

Data Reviewed: [Key labs, imaging, and home monitoring with dates and brief interpretation] (If critical data missing, document as care gap.)

Assessment & Plan

(Use problem-oriented format. Include only problems meaningfully assessed or managed today. For each problem, state status with metric and date, then actionable plan. Document rationale for therapy changes.)

• [Problem name] — [Status: controlled / uncontrolled / at goal / stable / worsening] ([relevant metric with date]). [Plan including medication decisions, lifestyle recommendations, monitoring with timing, referrals, and patient education as applicable]
• [Additional problem] — [Status] ([metric with date]). [Plan]

Medications Reconciled: [Yes / No / Partial] — [Changes made today: starts, stops, dose adjustments] (If incomplete, document limitation and plan to resolve.)

Follow-Up

[Return interval and modality]; [interim labs/studies with timing and how results will be communicated]; [escalation instructions with specific thresholds when applicable]