Genetic Counseling Follow-Up Note (Hybrid)

Date/Time: [date and time of encounter]

Patient: [name, DOB, MRN]

Genetic Counselor: [name, credentials]

Encounter Type: [in-person / telehealth (video) / telehealth (audio-only)]

Reason for Follow-Up: [result disclosure / interval family history update / reanalysis discussion / other reason]

Participants: [patient and any others present; include interpreter language if applicable]

Referring Clinician: [name, specialty]

Summary

(Write 3–5 brief bullets in plain language accessible to patients. Define genetic terms parenthetically. This summary should stand alone for quick reference.)

• [Reason for today's visit in plain language]
• [What changed since the initial consult that affects risk or testing strategy]
• [Key results discussed and what they mean]
• [Main decision(s) made today]
• [Most important next step(s) and timing]

Interval History and Pedigree Update

[Interval medical events, new diagnoses or symptoms, relevant reproductive history changes, and any new external records reviewed since the initial consult]

Patient's goals for this visit: [stated goals and questions]

Pedigree review: [state that pedigree was reviewed; summarize updates including new diagnoses in relatives, updated ages, deaths, new genetic test results in family members, and source of information] (Include ancestry or consanguinity updates only if clinically relevant. Note missing information and plan to obtain it.)

Prior testing context: [brief reference to prior patient or family testing and known limitations that inform current recommendations] (Include only if relevant to current strategy.)

Results Reviewed

(Include this section only if new results were discussed. For each test, identify the laboratory, test name, and report date.)

Test: [laboratory, test name, report date]

Result: [result category: pathogenic / likely pathogenic / VUS / likely benign / benign] in [gene(s)] (Use "variant," not "mutation." Include HGVS nomenclature and zygosity if applicable.)

Clinical interpretation: [interpretation tied to patient's phenotype and indication; use calibrated language such as "consistent with," "increases the likelihood of," or "does not rule out"; include uncertainty, limitations, and residual risk]

(Repeat the above block for each additional test as needed.)

Counseling and Assessment

Patient questions and decisional considerations: [patient-stated questions, goals, and any decisional conflict] (Use neutral language.)

Targeted education provided: [conditions discussed, inheritance pattern, penetrance and expressivity as relevant, and how risk was communicated]

Testing decisions and consent: [testing ordered / offered and declined] (If ordered, document: purpose and scope, possible result types, approach to secondary findings if applicable, limitations, recontact and reclassification expectations, and privacy considerations. If declined, state patient's reasoning in neutral terms.)

Psychosocial considerations: [brief observations that affected understanding or decision-making] (Include only if relevant.)

Assessment: [problem-oriented assessment for each indication addressed, stating the clinical question, key supporting evidence, assessment with calibrated certainty, and rationale for chosen next steps] (Clearly label any clinical inference. Add separate paragraphs for each indication if multiple are addressed.)

Plan

(Provide actionable recommendations with responsible party and timing.)

• Testing: [tests recommended or ordered with rationale and logistics; contingency plan if results are negative or inconclusive]
• Medical management: [screening, surveillance, and referrals categorized as recommended now, consider, or defer pending results; include responsible clinician and timing]
• Family implications: [relatives who should consider cascade testing; recommended approach; whether family letter was provided or discussed]
• Reproductive counseling: [partner testing, carrier screening, PGT, or prenatal diagnosis options with timing and referrals] (Include only if relevant.)
• Resources provided: [written materials, websites, or support organizations]
• Follow-up: [how and when results will be returned; next appointment or reanalysis interval; triggers for earlier contact]

Total time spent: [minutes] (Include only if billing by time.)

Signature: [Genetic Counselor name, credentials]

Cosignature: [Supervising clinician name, credentials] (Include only if applicable.)