Heart Failure Follow-Up Note

Date: [Date]

Patient: [Patient name]

Provider: [Provider name, credentials]

Visit Type: [routine follow-up / post-discharge / volume check / GDMT titration]

HF Snapshot

Phenotype: [HFrEF / HFmrEF / HFpEF / HFimpEF / Unknown]

NYHA Class: [I / II / III / IV / Unknown] (Date assessed: [date])

LVEF: [percentage / Unknown], [modality], [date]

Dry Weight / Today's Weight: [dry weight goal / Unknown] / [today's clinic weight] ([Δ vs last visit]; [Δ vs dry weight])

Key Labs: Creatinine/eGFR: [value / not available] ([date]); Potassium: [value / not available] ([date])

Devices: [ICD / CRT / implantable hemodynamic monitor] (Omit this line if no devices)

Interval History

[Chief concern and perceived trajectory since last visit]

• HF symptoms: [Dyspnea at rest/exertion, orthopnea, PND, edema, exercise tolerance, fatigue, dizziness—note changes since last visit]
• Home weight trend: [Baseline, recent values, adherence to daily weighing]
• Diuretic use: [Current regimen, PRN use and response, missed doses]
• GDMT tolerance/adherence: [Adherence, side effects including hypotension, bradycardia, cough, hyperkalemia, GU symptoms]
• Interval events: [Hospitalizations, ED visits, arrhythmias, new medications, NSAID/steroid use]

Objective

• Vitals: Weight: [today's weight] ([Δ vs last visit]; [Δ vs dry weight]); BP: [value]; HR: [value]; RR: [value]; SpO2: [value] (Include orthostatic vitals only if clinically relevant)
• Exam: JVP: [measurement/description]; Lungs: [sounds]; Cardiac: [rhythm/murmurs]; Abdomen: [distension/hepatomegaly]; Edema: [grade/location]; Perfusion: [warm/cool, cap refill]
• Data Reviewed: [Key labs with dates, echo summary, device interrogation findings as relevant] (State "reviewed," "pending," or "not available" as appropriate; do not paste full panels)

Assessment

[Synthesis in 2–4 sentences: overall status—stable/improved/worsening; volume status—hypervolemic/euvolemic/hypovolemic with supporting evidence from symptoms, weights, and exam; current NYHA class; primary clinical drivers]

• Volume status: [Conclusion] (Basis: [symptoms, weights, exam findings])
• Precipitants: [Dietary indiscretion / missed meds / arrhythmia / infection / ischemia / medication changes / none identified]
• Safety parameters for titration: BP [range]; HR [range]; Cr/eGFR [value]; K+ [value]; Limiting adverse effects: [none / specify]

Additional Problems: [Other active problems with brief assessment] (Omit if none beyond HF)

Plan

Volume Management

• Diuretics: [Current regimen] → [Changes today: dose/timing/duration]
• Target weight: [Goal weight] by [timeframe]
• Monitoring: Daily weights; labs ([tests]) recheck [date/interval]
• Escalation: [When to use PRN dose; when to call clinic; when to seek urgent care]

GDMT Status (For each class: agent/dose, action today; if not on therapy, state reason)

• ARNI/ACEi/ARB: [Agent and dose / not on] — [start / titrate / continue / hold] ([Contraindication/reason if not on])
• Beta-blocker: [Agent and dose / not on] — [start / titrate / continue / hold] ([Contraindication/reason if not on])
• MRA: [Agent and dose / not on] — [start / titrate / continue / hold] ([Contraindication/reason if not on])
• SGLT2 inhibitor: [Agent and dose / not on] — [start / titrate / continue / hold] ([Contraindication/reason if not on])
• Other HF therapies: [Hydralazine–nitrate / ivabradine / iron replacement] — [plan] (Include only if applicable)

Self-Management

• Daily weights: Weigh every morning after voiding; call if weight up ≥[threshold] lb in 24 hours or ≥[threshold] lb in 1 week
• Sodium/fluid: [Sodium limit / fluid limit if prescribed] (Omit if no restriction)
• Medication adherence: [Plan to support adherence]
• Activity: [Activity recommendation; cardiac rehab referral if indicated]

Follow-up

• Next appointment: [Interval and modality]
• Pre-visit labs: [Tests needed] by [date]
• Return precautions: [Worsening shortness of breath, rapid weight gain, chest pain, fainting, decreased urine output]

Additional Problem Plans: [Brief plan for each additional problem listed in Assessment] (Omit if none)