Laboratory/Imaging Results Review Note (Naturopathic Medicine)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifiers per local policy]

Provider: [Provider name, credentials]

Encounter Type: [in-person / video / phone / portal]

Reason for Visit: Review of [test(s)] results

Clinical Context

[Clinical indication and question prompting testing] (Provide a concise 2–4 sentence summary. Include only interval changes since ordering that affect interpretation—symptoms, new treatments, meaningful dietary/supplement changes. If no relevant interval changes, simply state why tests were ordered. Do not restate full history.)

Results Reviewed

(List each test or study. Prioritize abnormal and clinically meaningful findings first with values, units, and reference flags. Include key normal findings only if they answer the clinical question. Summarize rather than pasting entire panels. Note that full report is in chart.)

• [Test/Study name] | [Collection/performance date] | [Internal / external source] | [preliminary / amended] (Include status only if not final.)
  • [Key findings with values, units, reference flags—abnormal first, then pertinent normals]
  • [Trends: prior value(s) with dates, direction and magnitude of change] (Include when available.)
  • [Imaging impression and action-driving details] (For imaging only.)
  • [Limitations: specimen issues, fasting status, assay differences, image quality] (Include only if applicable.)
  • [Pending items: what is pending, expected timeframe, notification plan] (Include only if applicable.)
• (Repeat for each additional test/study. Full reports available in chart.)

Assessment

(Problem-oriented interpretation. Include only problems addressed today. Use appropriate uncertainty language such as "consistent with," "suggests," or "consider." Do not assert new diagnoses from nonspecific findings without noting confirmatory steps.)

[Problem 1: Condition or clinical question]

[Synthesis of what results mean in this patient, most likely explanation with supporting data, clinical significance and risk if relevant, and any limitations affecting interpretation]

[Problem 2: Condition or clinical question]

(Include additional problems only as addressed during the encounter.)

Patient Communication

• Modality/Recipients: [in-person / phone / video / portal message] to [patient and/or caregiver name(s)]
• Key points discussed: [What is normal, abnormal, and uncertain with plain-language explanations]
• Patient questions/concerns: [Questions raised and responses provided]
• Understanding confirmed: [Teach-back or confirmation of understanding]
• Shared decisions: [Decisions made together, options reviewed, and rationale] (Include only if applicable.)
• Urgent/Critical result handling: [Date/time result known, date/time patient notified, confirmation of receipt, immediate actions taken; if unable to reach patient, document attempts and escalation plan] (Include only for urgent or critical values.)

Plan

(Organize by problem when multiple issues are addressed. If no plan changes are needed, state this explicitly with reassurance given and follow-up timing.)

• Diagnostics/Monitoring: [Additional testing with timing and prep; monitoring parameters and frequency; imaging follow-up or comparison requests; pending result notification plan]
• Therapeutics: [Diet/lifestyle recommendations with specific targets and timeframes; supplements/herbs with substance name, form, dose, frequency, duration, indication, key safety points, and significant interactions; medications if within scope with name, dose, frequency, duration, indication]
• Referrals/Coordination: [Specialty, reason, urgency; communication with other clinicians] (Include only if applicable.)
• Safety Net: [Tailored red flag instructions: "Return sooner or seek urgent care if..."]
• Follow-up: [Specific interval and mode; what will be reviewed; how patient will be notified of pending results]

(Write clearly assuming the patient may read the note. Avoid unexplained abbreviations and judgmental phrasing. Use specific dates rather than "recent" or "previous" when referencing prior results.)