Epilepsy Follow-Up Clinic Note

Date: [Date]

Patient: [Patient name and identifiers]

Provider: [Provider name, credentials]

Encounter Type: [in-person / telehealth]

Chief Complaint

[Primary visit driver in one concise line] (Include brief patient wording in quotes only if it adds clarity.)

Interval History

[Brief summary anchored to last visit date with overall seizure control trend and key drivers of change] (Reference the last visit date. Include factors such as missed doses, sleep deprivation, illness, medication adjustments, or stressors only if explicitly reported.)

Seizure Inventory:

• [Seizure type]: [ILAE classification]; [Brief semiology]; [Frequency: daily / weekly / monthly / less than yearly / none in defined interval]; [Time since last event: exact date or time bucket] (Repeat for each active seizure type. Do not infer seizure freedom unless explicitly stated for a defined interval.)

Breakthrough Context: [Precipitants, circumstances, injuries, ED or hospital utilization] (Include only if seizures occurred since last visit; otherwise omit entirely.)

ASM Status: [Current ASMs with doses; adherence assessment; efficacy since last change; notable side effects or tolerability concerns]

Rescue Plan Status: [Rescue medication prescribed and available; seizure action plan in place] (Confirm current status; note if reviewed or updated this visit.)

Safety and Function: [Driving status and restrictions; work/school/activity limitations; living situation and supervision; sleep patterns; relevant substance use] (Include only items pertinent to this patient.)

Reproductive Considerations: [Pregnancy status or intentions; contraception; counseling provided this visit] (Include if applicable; omit if clearly not applicable.)

Objective

Vitals: [Relevant vitals including weight/BMI when dosing or side effects are pertinent]

Exam: [Focused neurologic exam findings: mental status, cranial nerves, motor, coordination, gait, evidence of injury] (Note exam limitations if telehealth.)

Data Reviewed: [EEG, MRI, ASM levels, and other relevant test results with dates and key impressions; note any pending studies] (Include only data reviewed or resulted since last visit.)

Assessment

[One- to two-sentence synthesis: epilepsy type and classification; current control status; key risk features; current ASM regimen. Include etiology or syndrome if known. Explicitly note drug-resistant epilepsy status when criteria are met or suspected.]

Plan

Medications: [Continue, adjust, or taper ASMs with target doses and titration schedule; rationale for changes; instructions for missed doses]

Rescue Plan: [Updates to rescue medication or seizure action plan; indications for use, dosing, and when to call EMS] (Include if new prescription or changes made; otherwise note 'Rescue plan reviewed, no changes.'))

Testing/Referrals: [EEG, imaging, labs, or referrals ordered with clinical indication] (Include only if orders placed this visit.)

Safety Counseling: [Driving counseling with state-specific restrictions; SUDEP counseling if clinically indicated; other safety topics addressed] (Document topics discussed; SUDEP counseling especially important with ongoing convulsive seizures.)

Screening: [Depression/anxiety screening instrument and score; plan for positive screens] (Include if performed this visit.)

Reproductive Counseling: [Annual counseling on folic acid, contraception interactions, and ASM effects on pregnancy/fetal development] (Document per AAN quality measure if applicable.)

Follow-Up: [Next appointment interval; instructions for earlier contact if needed]

(If critical information is unavailable—e.g., seizure frequency unknown or historian unreliable—document this explicitly. Do not infer seizure freedom or medication adherence without explicit patient or caregiver report.)