Menopause Management Note

Date: [encounter date]

Clinician: [name and role]

Visit Type: [new consult / follow-up / medication adjustment]

Uterus/Ovaries: [present / absent / unknown] (Required when systemic hormone therapy is being considered. If unknown, state plan to clarify.)

Subjective

Chief Concern: [one-sentence summary of primary reason for visit; may include brief patient quote]

Menopause Status: [menstrual history including LMP or reason for amenorrhea] [menopause context: spontaneous / surgical / iatrogenic / POI concern] [current hormonal contraception or hormone use] (If status is indeterminate due to hormonal contraception, endometrial ablation, or hysterectomy with ovaries intact, explicitly state why and outline a confirmation plan.)

Symptom Summary: [brief narrative of only the domains addressed today: vasomotor, genitourinary, sleep, mood, sexual concerns] (For each domain discussed, include onset, frequency, severity, and functional impact. Do not list domains that were not assessed.)

Pertinent History: [concise medical, surgical, and family history relevant to menopause care and treatment eligibility] (Prioritize thrombotic history, cancer history, surgical history including hysterectomy type and oophorectomy, medications affecting treatment selection, first-degree family history of breast/ovarian cancer or premature CVD, tobacco use, and relevant allergies. Omit unrelated history.)

Objective

Vitals: [BP, HR, weight/BMI as obtained]

Exam: [pertinent findings] (If pelvic exam performed for GSM or bleeding, note key findings. For telehealth, note exam limitations. Omit if none performed and none clinically indicated.)

Data Reviewed: [relevant recent results with dates: mammogram, cervical screening, DEXA, pertinent labs] (Only include results actually reviewed that inform today's decisions.)

Assessment

Menopause Stage: [perimenopause / postmenopause / surgical menopause / early menopause or POI / indeterminate] (If indeterminate, explain why and state confirmation strategy.)

Risk/Eligibility Summary: [summary of treatment eligibility considerations] (Include when considering systemic hormone therapy or fezolinetant: uterus status and need for endometrial protection; contraindications to systemic estrogen identified or none; key risk modifiers including age/time since menopause, VTE risk, breast cancer risk, cardiovascular risk. May abbreviate or omit if no prescription therapy is planned.)

Problem List:

1. [Problem 1 with brief rationale]
2. [Problem 2 with brief rationale] (Include additional items only if addressed today.)

Plan

[Problem 1]

Treatment: [recommendations and prescriptions with name, dose, route, frequency] (For systemic HT, document formulation rationale and endometrial protection if uterus present. For fezolinetant, document baseline LFT acceptability and monitoring schedule. For GSM in patients with breast cancer history, document stepwise approach and oncology coordination if local estrogen used.)

Counseling: [options discussed, patient goals and preferences, individualized risk-benefit discussion, patient's informed choice] (If patient declines recommended option, document reasoning and safety plan.)

Follow-up: [treatment goals, side effects to monitor, return precautions, follow-up timing, any orders or referrals placed]

[Problem 2]

Treatment: [as above]

Counseling: [as above]

Follow-up: [as above]

(Repeat problem subsections only for issues actually addressed today. For abnormal uterine bleeding or postmenopausal bleeding, explicitly document pattern, timing relative to HT use, and evaluation plan.)

(Document only what was obtained and discussed today. If safety-critical information is incomplete, note the gap and plan to clarify rather than omitting.)