DMARD Monitoring Note (Lab Review & Safety)

Date/Time of Review: [Date and time of review]

Encounter Modality: [in-person / telehealth / telephone / portal message / chart review only / infusion center]

Reason for Note: [Brief purpose of safety review]

Current DMARD Therapy

(List only agents under active safety surveillance. Do not duplicate full medication reconciliation.)

• [Medication name]: [Class: csDMARD / bDMARD / tsDMARD-JAKi], [dose/route/frequency], [indication], started [approximate start date], adherence [good / fair / poor / unknown]. [Relevant co-therapies if applicable, e.g., folic acid with methotrexate, concurrent corticosteroids.] [If recently held or discontinued, include date and reason.]
• (Repeat for each monitored agent.)

Interval Safety Screen

Information source: [phone / portal / in-person / chart review only / infusion center]

[Symptom screen summary with pertinent positives and negatives] (If patient contact occurred, document only items actually assessed: infections or fever; cytopenia symptoms such as bruising, mouth sores, severe fatigue; hepatic symptoms such as RUQ pain or jaundice; and drug-specific symptoms relevant to active agents. Do not record negatives that were not assessed.)

(If no patient contact occurred, replace the above with: No direct symptom screen performed; chart review only. Patient will be contacted if abnormal results require discussion.)

Monitoring Results

Specimen collection date: [Date]

• CBC: [WBC, ANC, Hgb, Platelets with trends vs prior if meaningful]
• Hepatic panel: [AST, ALT, total bilirubin with trends if relevant]
• Renal function: [Creatinine, eGFR with trends if relevant]
• Lipids: [Total cholesterol, LDL, HDL, triglycerides] (Include only for JAK inhibitors or IL-6 inhibitors; otherwise omit.)
• Non-lab monitoring status: [TB screening status and date; hepatitis B/C screening status; last ophthalmology exam for hydroxychloroquine; pregnancy test if clinically relevant] (Include only elements relevant to active therapy. If overdue or missing, state explicitly.)

(Include only values needed for DMARD safety interpretation. When information is missing or unknown, document it as such.)

Assessment

[Safety assessment and risk decision] (State whether monitoring results are acceptable for continued therapy. Identify emerging toxicity signals or actionable trends and tie them to relevant action thresholds. If results are acceptable without changes, state this explicitly and justify the monitoring interval.)

Plan

• [Agent name]: [continue / dose adjust / hold / discontinue] — [brief rationale linked to results or symptoms]. Next monitoring: [labs/tests and due date]. [Drug-specific counseling if patient contact occurred: infection precautions, when to hold during illness, pregnancy avoidance for teratogenic agents, visual symptom red flags for hydroxychloroquine, boxed warning discussion for JAK inhibitors as applicable.]
• (Repeat for each monitored agent.)

Communication: [Patient contacted via phone / portal / in-person / not reached]. [Key points discussed if contact occurred; if not reached, document attempts and contingency plan.]

(This is a focused DMARD safety monitoring note. If the encounter involves unstable disease or complex diagnostic decision-making, use a full visit note template.)