Chronic Disease Follow-Up Note (Multi-Problem)

Date/Time: [Encounter date and time]

Visit Type: chronic follow-up; [in-person / video / phone]

Clinician: [Clinician name, credentials]

Patient: [Patient full name and identifier]

Participants: [Caregiver/interpreter name and role] (Only include if present)

Chief Concern

[One- to two-line reason for visit capturing patient priorities; include brief patient quote if clarifying] (Keep concise. Reflect today's agenda.)

Interval History

[Brief narrative linking today's agenda to interval course since last visit] (Focus on trends; attribute information to patient report, device data, or records.)

Interval events: [ER visits, hospitalizations, new diagnoses, outside medication changes with dates and sources] (Omit if none.)

Per condition addressed today:

• [Condition name]: [Key symptoms and functional impacts; self-monitoring data summary with date range and source; medication adherence and tolerability; lifestyle/behavioral changes] (If logs unavailable, state unavailability and patient's recall. Attribute to patient report. Repeat for each condition addressed.)

Medications

[Medication reconciliation statement confirming list reviewed and updated with patient/caregiver] (If reconciliation not performed, state why.)

Relevant OTC/supplements: [Pertinent nonprescription agents] (Omit if none.)

Changes today: [Medication] [continue / start / stop / titrate] to [dose/schedule] — Reason: [tie to trend/symptoms/goals]; counseling: [key precautions] (List each change. Omit if no changes.)

Objective

Vitals today: [BP, HR, RR, Temp, SpO2, Weight, BMI as obtained] (For telehealth, note measurement source and limitations.)

Recent trends: [BP trend: last 3–5 values with dates, clinic vs home] [Weight/BMI trend] [Other pertinent trends such as home glucose averages with date range and source] (Present compactly or as small table.)

Focused exam: [Pertinent positives and negatives by system relevant to problems addressed] (Do not fabricate findings for exams not performed. For telehealth, note limitations.)

Data reviewed: (Include values with dates; note trajectory and whether at goal; highlight clinically meaningful changes; if overdue, note when last done.)

• [Chronic measure, e.g., A1c]: [value] ([date]); target: [goal]; trajectory: [improved / stable / worsening]
• [Additional labs, imaging, or screening scores as relevant to conditions addressed]

(When carrying forward prior information, label as "requires verification." Date-stamp and source any imported data.)

Assessment & Plan

(List problems in descending clinical priority. Emphasize longitudinal trends and patient-centered goals.)

[Problem name]

Status: [controlled / borderline / uncontrolled] — [Brief supporting evidence referencing trends, symptoms, adherence, tolerability]

Goal: [Clinical target(s)] [Patient-centered goal if applicable]

Plan: [Medication actions with rationale; lifestyle/behavioral interventions; education and shared decision-making; referrals if applicable]

Monitoring: [Home monitoring instructions with thresholds; labs/tests due with timing; safety monitoring and risk mitigation steps]

Follow-up: [Timeframe] [Items to complete before next visit]

(Repeat above block for each problem addressed.)

Orders and Instructions

Orders placed: [Labs, imaging, referrals, vaccinations, prescriptions as applicable] (Omit if none.)

Patient instructions: [Home monitoring steps; medication changes in plain language; lifestyle recommendations; return precautions and when to seek urgent care]

Care Gaps

[Item] - [done / ordered / deferred (reason)] (Optional; include only if relevant screenings or immunizations are due.)

Attestation

(Optional billing support; keep separate from clinical content.)

MDM: Problems addressed: [number/complexity]; Data reviewed: [labs/records/home data]; Risk: [minimal / low / moderate / high]

Time-based (if used): Total: [minutes]; Activities: [pre-visit review, history, exam, counseling, ordering, documentation, care coordination]

(Omit any section that has no content. Do not introduce findings for exams not performed.)