HIV Follow-Up Note

Date: [Visit date]
Patient: [Patient name or identifier]
Provider: [Provider name and credentials]
Visit Type: [in-person / telehealth]
Reason for Visit: [Reason for visit]

HIV Snapshot

(Update only when information changes. Omit items that are not applicable. Use explicit unknowns only for safety-critical items such as HBV status.)

• HIV diagnosis: [Year of diagnosis; AIDS/OI history if applicable]
• Current ART: [Regimen components and formulation, start date] (Include prior key regimen changes only if relevant to current care.)
• Most recent VL: [Value] on [Date] [Trend notation if relevant] (Do not copy forward without re-verifying date.)
• Most recent CD4: [Absolute count and/or %] on [Date] (Include if clinically relevant.)
• OI prophylaxis: [Current prophylaxis and indication] (Include only if on prophylaxis.)
• HBV status: [Immune via vaccine / Past infection / Chronic infection / Unknown] (If unknown, flag explicitly.)
• HCV status: [Antibody and RNA status with date] (Include only if relevant.)
• TB status: [LTBI / active / negative with test type and date] (Include only if relevant.)
• Key interactions/contraindications: [Notable drug–drug or condition-related cautions] (Include only active issues.)

Subjective

Since last visit on [Last visit date]: [Concise interval summary]

• ART adherence: [Patient-reported adherence; missed doses; barriers; tolerability] (Do not infer adherence from viral suppression; document the patient's report.)
• Interval events: [New symptoms, infections, hospitalizations, exposures] (Include only if reported.)
• Medications: [Current ART and relevant non-ART meds confirmed; interaction review performed]
• Sexual health/STI risk: [Partners; exposure sites; recent symptoms or known exposures; partner status/disclosure] (Document at least annually.)
• Social factors: [Housing, food, transportation, insurance, safety, mental health/substance use, other determinants affecting engagement] (Include only if discussed.)

Objective

Vitals: [Relevant vitals] (If telehealth, note limitations.)

Exam: [Focused exam findings aligned with visit purpose]

Labs/Results:

• VL trend: [Most recent value] on [Date]; [Prior value] on [Date] (Include 2–3 values if helpful for trend; indicate if pending or overdue.)
• CD4: [Absolute count and/or %] on [Date] (Include if clinically relevant.)
• Safety labs: [Relevant renal, hepatic, hematologic results with dates]
• STI testing: [Site-specific results with dates] (Mark pending tests as pending.)
• Other diagnostics: [Other relevant results with dates] (Include only if applicable.)

(Note if patient is overdue for routine monitoring.)

Assessment & Plan

(Organize by problem with highest priority first. For each problem: current status with dated values, brief assessment, and specific plan.)

HIV/ART Management

• Status: [Virologic status: suppressed / detectable] with VL [value] on [Date]; CD4 [value] on [Date]
• ART: [Continue current regimen / Change regimen with rationale]
• Adherence: [Summary of patient-reported adherence and barriers]
• Interactions/toxicities: [Review performed; actions if any]
• Monitoring: [Planned labs and timing] (For detectable viremia, specify repeat VL timing and escalation plan including resistance testing threshold.)

OI Prophylaxis

(Include only if indicated by CD4 count or OI history.)

• Current prophylaxis: [Agent, dose, indication, start date]
• Stop criteria: [CD4 threshold or duration for discontinuation]

Coinfections (HBV/HCV/TB)

(Include only if applicable.)

• Status: [Current status with dates]
• Plan: [Treatment, monitoring, referrals]

STI Screening/Treatment

(Include only if applicable.)

• Results: [Sites tested, results, dates]
• Treatment: [Therapy given if indicated]
• Retesting: [Interval for test of cure or repeat screening]

Immunizations

(Include as applicable; note CD4-related contraindications for live vaccines.)

• Given today: [Vaccines administered]
• Due/Deferred: [Vaccines due or declined with rationale]

Cancer Screening

(Include as applicable per HIV-specific guidelines.)

• Status: [Screening tests and dates]
• Plan: [Next due or referrals]

Metabolic/Cardiovascular

(Include as applicable.)

• Status: [ASCVD risk, lipids, glucose, blood pressure with dates]
• Plan: [Interventions including statin with interaction review if applicable]

Mental Health/Substance Use

(Include as applicable.)

• Assessment: [Mood, anxiety, substance use]
• Plan: [Therapy, medications, harm reduction, referrals]

Follow-up

• Next visit: [Interval and rationale]
• Lab follow-up: [Timing and how results will be communicated]
• Return precautions: [Symptoms warranting earlier contact]

Required elements in every note: current ART regimen, adherence statement, last VL with date (or pending/overdue status), and follow-up plan. Do not copy forward prior values without verifying dates.

Orders

• Labs: [Labs ordered]
• Medications: [New or changed prescriptions]
• Vaccines: [Vaccines administered]
• Referrals: [Referrals placed]