Genetic Medicine Follow-Up Note

Patient: [name, DOB/age, MRN]

Date of Service: [date]

Visit Type: [in-person / telehealth]

Providers: [attending clinician, genetic counselor if applicable]

Reason for Follow-Up: [post-test disclosure / interval phenotype update / reanalysis review / other indication]

Reason for Visit

[Reason for visit summary] (One to two sentences establishing the primary purpose of this follow-up; include a brief patient quote only if it meaningfully conveys concerns or goals.)

Interval History

Prior genetics evaluation: [date of last visit]; [working diagnosis or "no established molecular diagnosis"]; [key tests ordered and high-level outcomes]. (Keep concise; reference prior note rather than restating full details.)

Changes since last visit: [new symptoms, diagnoses, hospitalizations, specialist evaluations, developmental or functional changes, therapy or medication changes, social or access-to-care updates as relevant]. (Use explicit terms such as "unknown" or "not assessed" when information is unavailable.)

Family history update: [pedigree reviewed and updated / pedigree reviewed with no changes]; [new diagnoses in relatives, new births or deaths, or explicitly state no interval changes]. (Note adoption or limited family information if applicable.)

Testing & Results

(For each test discussed at this visit, summarize key findings; do not reproduce full report text.)

• [Test name] — [laboratory]; [pending / completed / reanalysis requested]

  • Result: [positive / negative / VUS / carrier / secondary finding]; [variant summary if applicable: gene, nomenclature, zygosity, classification]
  • Clinical interpretation: [phenotype correlation; what this result explains vs. does not explain; impact on differential] (Clearly distinguish laboratory classification from clinical correlation. For VUS, note it is not diagnostic and what evidence could inform reclassification. For pending tests, note expected turnaround and disclosure plan.)
• [Additional tests as applicable, using same structure]

Assessment

[Impression summary] (Four to eight sentences: current working diagnosis or state no molecular diagnosis established; key interval updates affecting interpretation; what testing explains and what remains unexplained; immediate clinical priorities.)

• [Problem 1]: [brief descriptor and status] (List in decreasing order of priority; include only if multiple distinct genetic issues exist.)
• [Problem 2]: [brief descriptor] (Include only if applicable.)

Plan

(Organize by problem when multiple issues exist; specify who, what, and when for each action item.)

• [Problem]
  • [Additional genetic testing or phenotyping with rationale]
  • [Condition-specific surveillance: modality, frequency, responsible specialty]
  • [Family/cascade testing recommendations: which relatives, test indicated, counseling provided]
  • [Referrals placed and reason]
  • [Key counseling documented: result interpretation, inheritance implications, VUS uncertainty, recontact expectations]
  • [Follow-up interval and results communication plan]

(Include only action items relevant to this patient. State explicitly if information was not assessed or is unavailable.)