Chronic Disease Follow-Up Note (Family Medicine)

Date: [Date] | Patient: [Patient name; DOB/age] | Provider: [Provider name, credentials] | Visit Type: [in-person / telehealth / phone]

Chief Complaint

Follow-up: [Chronic conditions addressed]; [Brief purpose of visit]

Interval History

[Narrative since prior visit: time anchor referencing last visit date; symptom status and control for each condition; home monitoring data summarized as averages or ranges; medication adherence and tolerability including missed doses or side effects; relevant lifestyle factors; interval events such as ER visits or hospitalizations; and patient priorities or goals for today] (Write as a cohesive paragraph. Use patient quotes selectively for goals, preferences, or refusals. Include medication reconciliation status here if not documented in Objective. If purely data review with no interval changes, use a brief statement such as "Here to review interval labs; no new symptoms.")

Objective

Vitals: [BP, HR, weight, BMI, and other relevant measurements] (Omit if not obtained; if expected but unavailable for safety-critical reasons, document "not obtained" with brief reason.)

Exam: [Pertinent findings by system relevant to conditions addressed] (Omit if stable follow-up with no exam performed.)

Data: [Relevant labs, imaging, and validated instrument scores with explicit dates and trend comparisons to prior values; include brief interpretation] [Medication reconciliation status and notable changes if not documented in Interval History] (Present trends as "value (date), prior value (date)." Only include completed results; omit planned or pending tests.)

Assessment & Plan

(List each condition addressed in order of clinical priority. For stable conditions with no changes, a single line is sufficient.)

• [Condition name]: [Current control status with supporting evidence] [Therapeutic plan including medication changes with doses and brief rationale] [Non-pharmacologic recommendations] [Monitoring orders with timing] [Referrals if needed]
• [Condition name]: [Status and plan as above]

Care Gaps: [Preventive items discussed including vaccines, screenings, and disease-specific surveillance with acceptance or deferral and brief reason if declined] (Omit if none addressed.)

Follow-up: [Return interval] [Contingency instructions for earlier return if applicable]