Integrative Medicine Follow-Up Note (Plan Update)

Date/Time: [Date and time of encounter]

Provider: [Clinician name and credentials]

Visit Type: [in-person / video / phone]

Data Sources: [Sources used today, e.g., patient report, device logs, portal questionnaires, labs]

(hint: Use for established patient integrative medicine follow-ups focused on progress tracking, adherence review, and iterative plan refinement. Not for initial consults, acute sick visits, or standalone procedure notes. Use neutral, open-notes-ready language. Do not infer adherence, side effects, or understanding—document only what is explicitly reported or observed. Omit subsections with no relevant content. If key information is unavailable, write "Unknown" or "Not available" with a plan to obtain it.)

Visit Focus

[1–2 line purpose and up to three priorities] (May include a brief patient quote in quotation marks.)

Interval History

[Timeframe anchor and brief narrative summary] (Begin with "Since last visit on [date]..." or "Over the past [X] weeks..." Summarize overall course and salient changes.)

• Symptoms & function: [Symptom trajectory and functional changes] (State better/stable/worse with brief specifics.)
• Goal status: [achieved / on track / partially met / not started / paused / revised today] [Brief note per active goal] (Include brief explanation if goals changed.)
• Adherence & barriers: [Adherence patterns and context] (Use nonjudgmental language; describe barriers as constraints.)
• Tolerability/adverse effects: [Tolerability of supplements, medications, or therapies; severity; management]
• Patient-reported outcomes: [Instrument name, score, date, and trend vs prior] (Include only if collected.)
• Interval events: [ER visits, hospitalizations, new diagnoses, or medication changes by other providers] (Include only if present.)

Objective

Vitals: [Vitals obtained] (For telehealth, specify patient-reported vs not obtained. Omit if not available.)

Exam: [Focused exam findings relevant to today's problems] (State "Exam not performed" or "Limited by video visit" if applicable.)

Current Regimen: [Reconciled prescription medications, supplements/botanicals, and integrative therapies with changes since last visit] (For supplements: include product, dose, and indication when known; if details unknown, document "unknown—patient to bring bottle.")

Data Reviewed: [Relevant labs, imaging, and patient-generated data with brief interpretation] (Include only data directly used in today's decisions.)

Assessment

(Numbered problem list ordered by clinical or patient priority. One to three lines per problem.)

1. [Problem 1]: [Working diagnosis or symptom-based assessment]; [improving / stable / worsening]. [Key contributing factors].
2. [Problem 2]: [Assessment]; [status]; [contributing factors]. (Include additional problems only if discussed today.)

Plan

(Organize by problem. Use Continue/Adjust/Stop/Start language. Include only domains addressed today.)

[Problem 1]

Goal: [Specific, measurable goal; patient's motivating value if relevant]

Interventions: [Continue/Adjust/Stop/Start actions across relevant domains: nutrition, movement, sleep, stress/mind-body, supplements, medications, therapies, referrals] (For new supplements: include indication, expected benefit metric, interactions considered, and stop criteria. Note shared decision-making if central to changes.)

Monitoring: [What will be tracked and reassessment timing]

Safety Net: [Warning signs; when to message clinic vs seek urgent care]

[Problem 2]

(Include only if additional problems were addressed today.)

Goal: [Specific, measurable goal]

Interventions: [Continue/Adjust/Stop/Start actions] (For new supplements: include indication, benefit metric, interactions, stop criteria.)

Monitoring: [Tracking plan and timeline]

Safety Net: [Warning signs and escalation plan]

Follow-up: [Timing, modality, and interim communication plan]

Time: [Total clinician time on date of encounter] (Include only if billing by time.)