Gout Follow-Up Note (Treat-to-Target ULT)

Date: [Date] | Patient: [Patient name] | Provider: [Provider name/credentials] | Visit Type: [in-person / telehealth]

Interval since last gout visit: [Time interval] | Interval since last ULT dose change: [Time interval]

Subjective

[Interval narrative summarizing timeframe since last visit and overall gout trajectory]

• Flare activity: [Flare count, joints involved, severity, triggers, treatments used and response] (State explicitly if no flares occurred.)
• ULT adherence: [Current agent, dose, frequency]; [Estimated missed doses]; [Information source: patient report / pharmacy data]; [Barriers or self-adjustments] (Do not infer adherence from laboratory values alone.)
• Prophylaxis status: [Agent, dose, tolerance, adverse effects] (If prophylaxis not used during titration, document reason.)
• Relevant comorbidities/medications: [CKD stage, cardiovascular disease, nephrolithiasis, diuretics, anticoagulants, significant drug interactions as applicable]

Objective

• Vitals: [BP, weight as relevant to medication decisions]
• Exam: [Focused musculoskeletal and skin findings] (Document when symptomatic or tophi present; for telehealth, note exam limitations.)
• Serum urate: [Value] | Target: [<6 mg/dL / <5 mg/dL] | At goal: [yes / no]
• SU trend: [Prior values with dates if available]
• Renal function: [Creatinine, eGFR] (Include when titrating ULT or selecting prophylaxis/flare therapy.)
• [Other safety labs as clinically indicated]

(If SU not checked since last dose change, note this and whether labs are being ordered.)

Assessment

Gout/Hyperuricemia: [Disease phenotype and severity including tophaceous status, erosive disease, flare frequency]. Treat-to-target status: [current SU] vs target [<6 / <5 mg/dL], [at goal / not at goal]. Interval flares: [summary]. Current regimen: [ULT agent and dose] with [good / partial / poor] adherence. Prophylaxis: [status and tolerance].

Secondary problems affecting gout management: [CKD stage, cardiovascular history, nephrolithiasis, drug interactions—include only those directly constraining management decisions]

Plan

• ULT strategy: Target SU [<6 mg/dL / <5 mg/dL] [with rationale if lower than standard]. Today: [continue / increase / switch] to [agent] [dose], starting [date]. Next titration checkpoint: [timeframe].
• Prophylaxis: [Agent, dose, planned duration, stop criteria] (If omitted, document contraindication and alternative safety plan.)
• Flare action plan: [Rescue medication with dosing instructions]; seek urgent evaluation if [criteria].
• Monitoring: [SU check timing after dose change]; [renal function monitoring if indicated]; [pre-specified next step if SU remains above target].
• Follow-up: [Visit interval] with [labs to obtain before visit].

(If information required for safe management is missing—recent SU, adherence status, renal function—explicitly note the gap and action to obtain it.)