Rheumatology Follow-Up Note (Treat-to-Target Chronic Disease)

Date/Time: [date and time]

Provider: [provider name, credentials]

Visit Type: [in-person / telehealth] (If telehealth, note exam limitations.)

Primary Diagnosis(es) Addressed: [diagnoses addressed today with phenotype if relevant]

Time Since Last Rheumatology Visit: [interval]

Interval History

[Trajectory since last visit: improved/stable/worse and why; major interim events such as flares, infections, hospitalizations; therapy changes with dates; symptom domains relevant to the diagnosis; medication experience including response, adverse effects, and adherence with source; whether prior T2T checkpoint was met.] (Include only domains relevant to patient's diagnosis and reported today. Document adherence only with a stated source. If any item was not assessed, state "Not assessed" with reason and follow-up action.)

Objective

Vitals: [relevant vitals] (If not assessed, state reason.)

Exam: [pertinent musculoskeletal findings including tender/swollen joint counts when performed; axial, enthesitis, dactylitis, skin/nail findings as relevant to diagnosis] (Include only systems examined today. Note telehealth limitations if applicable.)

Disease Activity Assessment:

• Measure: [instrument name, e.g., CDAI, SDAI, DAS28, DAPSA, ASDAS, BASDAI]
• Score and Category: [value] - [remission / low / moderate / high]
• Key Components: [joint counts, patient global, inflammatory markers as used]
• Trend: [prior value → current value]
• Interpretation: [on track to target / not on track] (Note confounders such as fibromyalgia, osteoarthritis, or pain amplification if present.)

(If validated score not captured: "Validated score not captured; clinical impression: [assessment]; plan to capture at next visit.")

Data Reviewed: [labs with dates, imaging, outside notes relevant to today's decision-making]

Assessment

(Organize by problem in descending clinical priority.)

[Condition 1]

[Current disease activity category with instrument used; trend versus prior and whether on track to target; key drivers including objective inflammation vs pain amplification and active domains; medication effectiveness and tolerability; specific findings prompting escalation/switch/taper if applicable.]

[Condition 2]

[As above.] (Include only if addressed today.)

[Other considerations impacting decisions such as glucocorticoid-related risks, monitoring concerns, relevant comorbidities.] (Include only if relevant today.)

Plan

(For each condition addressed. Ensure medication plan matches changes in Assessment.)

[Condition 1]

• Target: [remission / low disease activity] (Provide rationale if individualized.)
• Medication Plan: [continue / escalate / switch / taper] - [drug, dose, route, frequency, duration as relevant; steroid taper schedule if applicable]
• Monitoring: [labs ordered with timing; safety screening due and status such as TB, hepatitis, HCQ eye exam]
• Decision Rule: [explicit checkpoint, timeframe, and contingency, e.g., "If CDAI not improved by 12 weeks, will discuss bDMARD"]
• Safety Counseling: [risks discussed, return precautions, shared decision-making] (Include only when therapy changed or material risks discussed.)
• Follow-up: [interval and modality tied to T2T checkpoint]
• Orders: [medications started/stopped/changed; labs/imaging ordered; referrals]

[Condition 2]

(Repeat structure above if additional condition addressed today.)