Movement Disorders Clinic Note

Date: [date]
Patient: [patient name or identifier]
Clinician: [clinician name and credentials]
Visit Type: [New / Follow-up / Programming / Telehealth]
History Source: [patient / caregiver / interpreter]
Medication State at Exam: [ON / OFF / Partially ON] | Last dopaminergic dose: [time]

Chief Concern

• [Patient-quoted primary concern] (Optional; include only if clinically useful)
• [Clinician-defined visit objective 1]
• [Clinician-defined visit objective 2] (Limit to 1–3 bullets total)

Interval History

[2–4 sentence summary: working diagnosis/phenotype, disease duration, and current primary functional limitations or treatment goals] (For follow-ups, emphasize interval changes; avoid re-copying baseline history)

Medication Schedule and Response (Include only relevant changes since last visit)

Medication	Dose	Time(s)	Notes/Response
[name/formulation]	[mg]	[times]	[response/side effects/adherence notes]

• [Latency to ON, duration of benefit, wearing off predictability]
• [Overnight/morning OFF periods]
• [Motor complications: dyskinesia timing/distribution; OFF dystonia]
• [Adverse effects: hallucinations, orthostasis, impulse control behaviors, cognitive changes]
• [Adherence barriers]

(Include only items that are present or changed)

Motor Symptoms (Document only what is relevant and changed)

• [Tremor: rest/postural/kinetic, distribution, variability]
• [Bradykinesia and dexterity]
• [Gait/balance: freezing triggers, fall frequency]
• [Speech/voice and swallowing]

Non-Motor Symptoms (Screen briefly; expand on positives; mark unassessed domains as "Not assessed")

• [Cognition]
• [Mood/anxiety/apathy]
• [Psychosis]
• [Sleep]
• [Autonomic: constipation, urinary, orthostasis, other]

Function and Safety (Include only items with interval change or active concern)

• [ADLs/IADLs and caregiver support]
• [Driving status]
• [Exercise/PT adherence]
• [Assistive devices]
• [Falls since last visit: count, context, injuries] (Explicitly document any injuries)
• [Dysphagia risk and diet modifications]
• [Living situation and supervision level]

Red Flags (Include only when diagnostic certainty is in question; otherwise omit entirely)

• [Early falls/rapid postural instability: present / absent]
• [Prominent autonomic failure: present / absent]
• [Vertical gaze palsy: present / absent]
• [Cerebellar or pyramidal signs: present / absent]
• [Poor levodopa response: present / absent]
• [Other atypical features]

Objective

Vitals: [BP, HR, weight; orthostatics if indicated]

Exam Conditions: Motor exam performed [ON / OFF / Partially ON]; last dopaminergic dose at [time]; exam at [time]. (Note medications that may influence tremor assessment or telehealth limitations if applicable)

Neurologic Exam

[Narrative synthesis of key findings: mental status, speech/voice, overall motor state]

• [Eye movements] (Include if atypical parkinsonism suspected)
• [Tone/rigidity: distribution and laterality]
• [Bradykinesia: finger/hand/foot taps, amplitude decrement]
• [Tremor: rest/postural/kinetic; amplitude, distribution]
• [Dystonia: pattern and triggers]
• [Dyskinesia: distribution and severity]
• [Gait: stance, stride, arm swing, turning, freezing]
• [Postural stability/pull test]

Scales: [Scale name] performed [ON / OFF], last dose at [time]; completed by [clinician / patient / caregiver]; score: [value] — [brief interpretation] (Include only scales actually administered)

Data Reviewed: [Relevant imaging, labs, outside notes, therapy reports, device interrogations] (Include only if reviewed)

Assessment

(Problem-oriented in descending clinical importance; do not introduce new patient-reported data here)

[Problem 1]: [Diagnosis or syndrome] — [improved / stable / worsened]

[Supporting history and exam features; differential and diagnostic confidence when relevant] (For parkinsonism, explicitly document cardinal features, supportive features, and presence/absence of red flags or exclusion criteria; if uncertain, label as "parkinsonism" with leading possibilities)

[Problem 2]: [Diagnosis or syndrome] — [improved / stable / worsened]

[Brief justification] (Include only problems addressed at this visit)

Plan

(Organize by problem; link rationale to symptom pattern)

[Problem 1]

• Medications: [Exact dosing schedule with times; titration steps with dates; monitoring instructions; tapering if deprescribing]
• Rehabilitation: [PT/OT/SLP referrals with goals; exercise plan; assistive devices; home safety evaluation]
• Safety: [Falls risk mitigation; dysphagia precautions; psychosis/impulse control management]
• Advanced Therapy: [Candidacy rationale; contraindications reviewed; workup ordered; shared decision-making discussion] (Include only if discussed)

[Problem 2]

• [Medications, rehabilitation, safety interventions as applicable]

Follow-up: [Timeframe] — [What to monitor before next visit; patient tasks such as dose timing diary, falls log, dyskinesia tracking]