DMARD/Biologic Initiation Note (Screening & Counseling)

Date/Time: [Date and time of documentation]

Setting: [office / telehealth / phone]

Provider: [Provider name and credentials]

Patient: [Patient name and identifier]

Medication Initiation Plan

Medication: [Generic name — dose — route — frequency]

Start timing: [immediate / deferred pending screening or vaccination] (Include planned start date if deferred.)

Adjuncts/bridging: [Bridging therapy or adjunctive medications with dose/frequency] (e.g., folic acid, antiviral prophylaxis, corticosteroid taper)

Concomitant DMARDs/biologics: [Agent — continue / hold / discontinue] (List each agent and plan.)

Indication & Treatment Rationale

Primary diagnosis: [Condition/diagnosis]

Disease activity supporting escalation: [Key indicators — symptoms, exam findings, activity scores, steroid dependence, recent flares]

Rationale for medication choice: [Guideline-based step-up / prior therapy failures / patient preference / comorbidity or access considerations]

Prior therapy history: [Agent — dose — duration — reason stopped] (Include therapies relevant to step-therapy or prior authorization. Repeat as needed.)

Cross-reference: [Reference to same-day clinic note if detailed rationale documented elsewhere]

Baseline Screening

(Document result, date, and source for each item. Clearly distinguish completed from pending items. If unavailable, document as unknown with explicit plan.)

Labs: [Relevant baseline labs — result — date — source] (Include CBC, CMP, inflammatory markers; add lipids if indicated by drug class.)

TB Screening: [IGRA or TST — result — date — source] (If positive/indeterminate: document imaging, ID referral, LTBI treatment plan, or start deferral. For prior treated LTBI/TB: note year and completion status.)

Hepatitis B: [HBsAg / anti-HBs / total anti-HBc — results — dates — source] — Interpretation: [susceptible / immune / chronic infection / past infection]. (If chronic/past infection: state reactivation mitigation plan and responsible service. If susceptible: note vaccination plan.)

Other infection screening: [HCV, HIV, or other screens — result — date — source] (Include only if required by drug label, institutional policy, or patient risk profile. Omit if not applicable.)

Vaccinations: Source of immunization history: [registry / EHR / PCP records / patient-reported]. Status for: [influenza / pneumococcal / recombinant zoster / COVID-19 / hepatitis B if susceptible — status and dates]. Timing plan relative to medication start: [immediate start / defer for live vaccine washout / administer prior to start]. (If records incomplete, document plan to obtain or administer per schedule.)

Reproductive considerations: [Pregnancy status — pregnancy test result and date if required] [Pregnancy intention] [Contraception plan] [Teratogenicity counseling documented] (Include only if clinically relevant to medication choice. Omit section entirely if not applicable.)

Pending/unavailable items: [Test or record — status — orders placed — expected timing — effect on medication start (proceed vs defer) with rationale] (List any screening items not yet completed.)

Counseling & Shared Decision-Making

(Document as narrative summary tailored to medication class.)

Benefits discussed: [Symptom control / damage prevention / steroid-sparing / functional improvement]

Material risks reviewed: [Infection risk / TB or HBV reactivation / malignancy warnings / lab abnormalities requiring monitoring / infusion or injection reactions / cardiovascular or thrombotic risks] (Tailor to drug class. Include JAK inhibitor boxed warning discussion if applicable.)

Alternatives discussed: [Alternative agents or classes considered]

Patient questions and understanding: [Questions addressed — understanding confirmed]

Decision: [agrees to proceed / defers / declines — reason if provided]

Monitoring & Follow-up Plan

Lab monitoring: [Labs to monitor] — [frequency during initiation] then [maintenance frequency] — [where drawn] — [who reviews and communicates results]

Clinical monitoring instructions: [Symptoms requiring urgent contact / when to hold medication / infection or surgery precautions]

Follow-up: [Timeframe — modality — responsible clinician]

Shared care: [Division of monitoring responsibilities if applicable — specify which provider monitors what]

Orders placed: [Labs / vaccines / imaging / referrals / prior authorization / pharmacy coordination]