Growth Hormone Therapy Start Note

Date: [Date of service]

Patient: [Patient name, DOB, MRN]

Provider: [Provider name, credentials]

Primary Indication: [Indication] (Use standardized terminology: Pediatric GHD, Turner syndrome, Adult GHD, etc.)

Therapy Status: [New start / Restart / Transition from pediatric to adult]

Clinical Context

[Narrative summary of why growth hormone therapy is being initiated now] (Include reason for timing; summarize diagnostic confirmation with test type, date, and key result establishing eligibility; outline prior management and alternatives considered; document patient/caregiver goals. If prior GH exposure exists, note product, duration, response, and any adverse effects. If diagnostic confirmation or outside records are incomplete, explicitly state missing elements and plan to obtain them rather than inferring criteria were met.)

Baseline Status

Relevant History: [Pertinent conditions affecting indication, dosing, or safety; current medications; allergies] (Include only items relevant to GH therapy: pituitary disease, malignancy history with remission status, scoliosis, OSA, diabetes, thyroid/adrenal disorders, glucocorticoids, thyroid replacement, diabetes therapies.)

Safety Screen: [Targeted symptom review with pertinent positives and negatives] (Address: headache or visual changes; hip/knee pain or limp; snoring/apnea or sleep-disordered breathing; edema, arthralgia, paresthesias; metabolic symptoms such as polyuria/polydipsia.)

Measurements: [Height, weight, BMI with percentile or SDS; growth velocity with interval dates; pubertal staging for pediatrics; bone age with date if obtained; blood pressure and waist circumference for adults if captured] (Use standard units; include dates for all measurements.)

Exam: [Focused physical exam relevant to GH risks and comorbidities] (Include pertinent positives and negatives for: general appearance; visual fields/fundoscopy if indicated; thyroid; cardiovascular; musculoskeletal including hips/knees and scoliosis screen; skin/edema.)

Data Reviewed: [Diagnostic confirmation data with dates and interpretation] (Include GH stimulation testing with peak GH; IGF-1 with SDS; pituitary imaging; genetic testing as applicable. Baseline labs: thyroid function, glucose/HbA1c, lipids. For each item indicate: [reviewed / ordered / pending]. Do not list planned items as completed.)

Assessment

Primary Indication: [Indication with specific criteria met, supporting evidence, and dates]

Relevant Comorbidities: [Conditions that modify risk, dosing, or monitoring] (Omit if none.)

Contraindication Screen: [No contraindications identified / Contraindication or concern identified: [description] with plan: [risk mitigation or deferral]]

Plan

Eligibility: [Summary of criteria met with supporting data and dates; epiphyseal status for pediatric growth indications: [open / closed / pending imaging] with date]

Product and Dosing: [Medication name, formulation, device type; calculated dose with weight and date used; injection frequency and timing; start date or conditions for start; titration plan with targets; prior authorization status and alternatives if PA pending]

Education: [Injection teaching: [completed today / scheduled for date]; learner(s); competency validation via [teach-back / return demonstration]; supplies prescribed] (Do not document teaching completed unless competency validation is described.)

Discussion: [Benefits tailored to indication; key risks reviewed with patient-specific modifiers; alternatives addressed; consent obtained; assent if applicable]

Monitoring: [Early safety check timing with planned labs; ongoing monitoring intervals for growth response and adverse effects; annual reassessment plan]

Orders: [Medication order; laboratory orders with timing; referrals as indicated]

Return Precautions: Headache or vision changes; hip or knee pain or limp; new or worsening snoring or apnea; significant edema or joint pain; severe abdominal pain. [Contact instructions; next appointment timing]

[Total clinician time: [minutes]] (Include only if billing by time; omit entire line if billing by medical decision-making.)