Rheumatoid Arthritis Treat-to-Target Visit Note (Disease Activity & Function)

Date: [Date]

Patient: [Patient name / MRN]

Provider: [Provider name, credentials]

Encounter Type: [in-person / telehealth - video / telehealth - audio-only]

Visit Reason: [RA treat-to-target follow-up / other]

T2T Status

Target: [remission / low disease activity] by [tool name], threshold: [numeric cutoff] (If individualized target, briefly state rationale.)

Disease Activity: [Tool name] = [numeric score]; category: [remission / low / moderate / high]; at target: [yes / no]. Trend: [prior values with dates if available]. (If not performed, state reason and plan.)

Functional Status: [PROMIS PF10a / HAQ-II / MDHAQ / other] = [score]; comparison to prior: [improved / stable / worsened]; last assessed: [date]. (If due but not performed, state reason and plan.)

Current Regimen: [Current DMARDs with dose/route/frequency]; Glucocorticoid: [none / current exposure]; Changes today: [medication changes with brief rationale, or none].

Subjective

[Interval RA history since last visit: flare episodes, morning stiffness duration, joint pain/swelling pattern, fatigue, functional limitations, patient global impression of change. Include PRO scores if captured. Document medication adherence, perceived effectiveness, adverse effects, and infections since last visit. Targeted ROS only if relevant; otherwise omit or note ROS negative.]

Objective

Exam: TJC28 = [value]; SJC28 = [value]. [Key involved joints and pertinent extra-articular findings.] (For telehealth, document modified assessment method and limitations.)

Labs/Data: [ESR/CRP if used in score]; DMARD safety labs reviewed [date]: [key abnormalities or none]. Adequate for planned therapy: [yes / no with plan]. [Imaging only if changes management.]

Assessment

Rheumatoid Arthritis: Current disease activity: [category from tool]; target status: [at target / not at target]. Concordance: [concordant / discordant — if discordant, note contributing factors such as fibromyalgia, OA, structural damage]. Functional trajectory: [improving / stable / declining]. Medication response: [adequate / partial / primary failure / secondary failure / intolerance]. [Comorbidities only if affecting target or escalation decisions.]

[Additional problems only if discussed and relevant to this encounter.]

Plan

RA Treat-to-Target: Target: [remission / LDA] by [tool] ≤[threshold]. Current status: [at target / not at target].

• If at target: [Maintenance strategy]; follow-up in [interval].
• If not at target, escalating: [Escalation plan with rationale]; alternatives discussed: [options]; reassess in [timeframe].
• If not at target, not escalating: Justification: [reason]; discussion held: [summary]; interim management: [plan]; reassessment: [specific timeline with plan to recheck disease activity tool].

Monitoring: [Lab schedule and next due]; [infection/vaccination/reproductive health updates if applicable].

Non-pharmacologic: [PT/OT, exercise, assistive devices — include only if relevant to this visit.]

Follow-up: [Interval] based on disease activity; will measure [disease activity tool, functional status if due]; pre-visit: [labs/imaging to obtain].

(Omit sections not relevant to the encounter. Do not infer disease activity category or functional status from narrative—require documented standardized scores. For telehealth, document modified assessment methods and limitations.)