Chronic Disease Recheck Note

Date/Time: [Encounter date and time] | Patient: [Patient identifiers] | Provider: [Provider name and credentials] | Visit Type: [in-person / telehealth] | Reason for Visit: [Chronic disease follow-up reason]

Chief Concern

[Patient-stated reason or clinician chronic-care monitoring agenda] (Keep to one to two lines; a brief patient quote is acceptable.)

Interval History

[Reference to last visit date and significant interim events] (Include ED visits, hospitalizations, new diagnoses, or care transitions since last visit; omit if none.)

[Concise narrative of interval change] (Summarize what has changed since the last visit: current status of each condition addressed today as improved/stable/worsened, relevant symptoms and functional impact, adherence and barriers, home monitoring data with time window and patterns, and patient goals or questions if documented. Include focused review of systems only when symptoms materially affect today's assessment or plan.)

Medications

[Medication reconciliation statement] (State that the medication list was reviewed and reconciled with the patient; note discrepancies resolved.)

[No changes to chronic medications / Changes made today:]

• [Medication name and dose] — [start / stop / increase / decrease] (Rationale: [link to goals or clinical data]. Monitoring: [parameters, timing, responsible party].)
• (Repeat for each medication change; omit bullet list if no changes.)

Objective

Vitals: [Relevant vitals pertinent to conditions addressed]

Exam: [Pertinent positives and negatives by system, focused on addressed problems]

Data: [Key labs, imaging, and test results with trend information] (Show at least two to three time points with directionality and whether at goal. Note any expected but unavailable data with reason and follow-up action.)

Assessment & Plan

(Use problem-oriented format. Order by acuity/safety risk, then morbidity impact, then patient priority. Keep reasoning to one to three sentences per problem.)

[Problem label — stage/severity/control status]

[Current status and interval change with brief supporting data]

• Goal: [Individualized target; note patient agreement]
• Plan: [Medication changes, nonpharmacologic interventions, monitoring with frequency, referrals, risk mitigation, return precautions, and follow-up interval for this problem] (Include only elements that apply.)

(Repeat problem structure for each chronic condition addressed. For expected problems not discussed, note "[Problem] — Not addressed today" without a plan.)

Overall follow-up: [Next visit timing and modality; labs or monitoring to complete before visit]

(If safety-critical information is missing—such as key labs for dosing decisions or unclear medication sources—document what is missing, why, and follow-up action. Omit this note if not applicable.)