Osteoporosis/Osteopenia Evaluation Note

Date of Service: [Date of service]
Provider/Credentials: [Provider name, degree(s), and credentials]
Encounter Type: [initial evaluation / re-establishing care]
Referring Clinician: [Referring clinician name and credentials] (Only include if applicable)
Reason for Referral: [Reason for referral] (Only include if applicable)

Bone Health Summary

(Compact snapshot populated from details documented elsewhere in this note. Include only items that are available; omit noncritical missing elements.)

• [Working diagnosis and basis: osteoporosis vs low bone mass; DXA site and T-score, fragility fracture, or vertebral fracture on imaging]
• [Key fractures: site and date]
• [Most recent DXA: date, sites measured, lowest T-score]
• [FRAX results: 10-year hip % and major osteoporotic fracture %] (Only include if calculated)
• [Key safety labs: calcium, 25-OH vitamin D, eGFR]
• [Current/recent osteoporosis medications with last administration date] (Include last denosumab or IV bisphosphonate date if applicable)
• [Major risk flags: recent falls, glucocorticoid exposure, CKD, planned dental procedures]
• Data gap: [Critical missing information and retrieval plan] (Only include if critical data is missing, e.g., unknown last denosumab dose)

Chief Complaint

[Reason for bone health evaluation]

History of Present Illness

[Narrative describing how low bone density/osteoporosis was identified, mechanism of any fracture, and current symptoms suggesting progression. For re-establishing care, summarize prior diagnosis and treatment course. Include patient preferences and constraints relevant to therapy selection. Use direct patient quotes when clarifying fracture mechanism, adherence barriers, or symptom impact.] (Do not label a fracture as fragility/osteoporotic without documenting low-energy mechanism or clinician rationale.)

Fracture History

(Document each fracture with: Date — Site — Mechanism — Imaging confirmed — Treatment — Sequelae. Explicitly state "none known" or "unknown" if no fractures can be confirmed.)

• [Date — Site — Mechanism/energy level — Imaging confirmed: yes/no — Treatment — Sequelae]

Osteoporosis Risk Factors and Secondary Causes

• Primary risk factors: [Age, menopausal status/age at menopause, BMI or significant weight loss, parental hip fracture: yes/no/unknown, tobacco use, alcohol intake, fall history with number in past year, prior fractures or osteoporosis diagnosis]
• Secondary causes considered: [Hyperparathyroidism, hyperthyroidism, hypogonadism, celiac disease/malabsorption, CKD, chronic liver disease, inflammatory disorders, myeloma features, malignancy] (Specify suspected vs ruled out vs pending in Assessment)
• Medications affecting bone: [Glucocorticoids with dose/duration/current vs prior, aromatase inhibitors, androgen deprivation therapy, anticonvulsants, PPIs, other]
• Dental considerations: [Planned extractions/implants or active dental issues] (Only include if relevant to antiresorptive decisions)

Past Medical and Surgical History

• [Bone-relevant conditions and surgeries: prior fracture repairs, spine/hip procedures]
• [Esophageal disorders relevant to oral bisphosphonates]
• [Bariatric surgery or malabsorption history]
• [CKD stage]
• [Nephrolithiasis history]
• [Cardiovascular disease history] (Relevant to romosozumab risk assessment)

Osteoporosis Medication History

(One entry per therapy in timeline format. Explicitly capture last denosumab injection date and last zoledronic acid infusion date when applicable.)

• [Agent/route — Start to stop date — Adherence — Response: DXA change, fractures on therapy — Reason stopped]
• Last denosumab injection: [Date or unknown] (If unknown, document retrieval plan before therapy decisions)
• Last zoledronic acid infusion: [Date] (Only include if applicable)

Current Medications

• [Medication list with doses and frequencies]
• [Calcium supplement: formulation, dose, adherence]
• [Vitamin D supplement: form, dose, adherence]

Allergies and Intolerances

• [Allergen — Reaction description] (Differentiate bisphosphonate GI intolerance from true allergy when known)

Social History

• [Tobacco use status]
• [Alcohol intake: drinks per week]
• [Living situation and fall hazards]
• [Physical activity: weight-bearing, resistance, and balance exercise]
• [Dietary calcium intake pattern]

Family History

• Parental hip fracture: [yes / no / unknown]
• [First-degree relatives with osteoporosis or fragility fractures]

Physical Examination

• Height: [Height] (Include comparison to historical height if available) Weight: [Weight]
• Posture: [Kyphosis assessment]
• Spine: [Tenderness findings]
• Gait/balance: [Observation findings, assistive device use]
• Lower extremity strength: [Findings] (Only include if assessed)

DXA Review

[Narrative interpretation with diagnostic classification and basis] (Avoid terms like "mild/moderate osteopenia." Do not describe trends without valid prior comparator.)

• DXA date/facility: [Date, facility]
• Lumbar spine: [BMD, T-score] (Note excluded vertebrae if applicable)
• Femoral neck: [BMD, T-score]
• Total hip: [BMD, T-score]
• Diagnostic classification: [Normal / low bone mass / osteoporosis] with basis
• Artifacts/limitations: [Degenerative changes, scoliosis, hardware, positioning issues] (Only include if present)
• Trend vs prior: [Comparator date, percent change by site, clinical significance vs LSC] (Note if cross-platform comparison limits interpretation)

Vertebral Imaging

(Only include if VFA, spine X-ray, or CT/MRI findings are available)

• Modality/date: [Modality and date]
• Findings: [Presence/absence of vertebral fractures, levels involved]
• Clinical implications: [Management relevance]

FRAX Assessment

(Only include if FRAX was calculated for this encounter)

• Calculated with femoral neck BMD: [yes / no]
• Risk factors included: [Factors entered]
• 10-year hip fracture risk: [Percentage]
• 10-year major osteoporotic fracture risk: [Percentage]
• Assumptions for unknown inputs: [Document any unknowns assumed as "no"]

Laboratory Review

Baseline safety labs:

• [Date — Calcium (corrected if applicable): Result (Ref)]
• [Date — 25-OH Vitamin D: Result (Ref)]
• [Date — Creatinine/eGFR: Result (Ref)]

Secondary cause evaluation: (Include tests ordered based on clinical suspicion)

• [Date — Test: Result (Ref)]
• [Ordered/pending tests and rationale]

Assessment

(Problem list format. For re-establishing care, do not downgrade diagnosis solely due to current T-score if historical criteria for osteoporosis were previously met.)

1. Low bone mass or Osteoporosis: [Diagnosis with basis: DXA site/T-score/date, vertebral fracture on imaging, or fragility fracture with mechanism]
2. Fracture risk characterization: [Risk level and rationale: recent fracture, very low T-score, multiple fractures, high fall risk, glucocorticoids]
3. Secondary osteoporosis evaluation: [Suspected / ruled out / pending workup] with leading considerations
4. Fall risk: [Present / absent] with contributing factors (Document separately so interventions are clear)
5. Calcium and vitamin D status: [Deficient / insufficient / adequate / uncertain] with supporting data

Plan

(Problem-oriented, addressing highest-risk issues first. Document only screening/contraindication checks that were actually performed.)

Non-pharmacologic Management

• Calcium: [Daily elemental calcium goal, dietary vs supplement strategy]
• Vitamin D: [Target level, dosing regimen, recheck timing]
• Exercise: [Weight-bearing, resistance, balance training recommendations]
• Lifestyle: [Smoking cessation, alcohol moderation]
• Fall prevention: [Home safety, vision/hearing, footwear, medication review]

Pharmacotherapy

• Medication selected: [Agent and rationale tied to risk profile and patient preferences]
• Contraindication screening: [Screens performed: esophageal disorders, hypocalcemia risk, CKD stage, cardiovascular history for romosozumab]
• Administration and counseling: [Instructions provided, adverse effects discussed]
• Sequencing/transition plan: [Plan for denosumab initiation/continuation/discontinuation with transition strategy] (Denosumab discontinuation requires transition to alternative antiresorptive)
• Monitoring: [Labs, symptoms, repeat DXA timing with rationale]
• Duration and reassessment: [Expected duration, triggers for reassessment]
• Shared decision-making: [Options discussed, patient preferences, risk-benefit counseling, rationale for chosen approach]

Secondary Cause Workup

• [Tests ordered and purpose]
• [Referrals placed]
• [Results review timing]

Fall Risk Reduction

(Include when fall risk is present or fragility fracture history exists)

• [Medication review and adjustments]
• [Vision assessment/referral]
• [PT/OT referral for balance and strength]
• [Home safety evaluation, assistive devices]
• [Syncope evaluation if indicated]

Symptom Management

(Only include if vertebral compression fracture symptoms are present)

• [Analgesia plan]
• [Mobility aids and PT referral]
• [Imaging follow-up triggers]

Follow-up and Monitoring

• Lab review: [Timing, e.g., 6–12 weeks after vitamin D repletion or medication initiation]
• Next DXA: [Timing and clinical rationale]
• Follow-up visit: [Timing]
• Return precautions: [New fracture, severe back pain, hypocalcemia symptoms, thigh/groin pain on long-term bisphosphonates]

Attestation

[Provider signature and credentials]