Shared Medical Appointment/Group Medical Visit Note

Visit Details

Date: [Visit date]

Location/Modality: [in-person / telehealth / hybrid]

Visit Type: Shared Medical Appointment / Group Medical Visit

Program/Session: [Program or series name; session number if applicable]

Rendering Clinician: [Name, credentials]

Team Members Present: [Roles and names if applicable]

(The Group Component content should be clinically identical across all participants' notes; only the Individual Patient Component varies per patient. Omit any sections not applicable rather than leaving empty placeholders.)

Group Component

Consent/Confidentiality: [Statement confirming patient agreed to group format and confidentiality expectations reviewed, or that series-level consent is on file and reaffirmed today]

Session Overview: [Total duration in minutes; format such as didactic, facilitated discussion, or skills practice; group size as count only] (Never list participant names or identifiers.)

Education Delivered: [Topics covered with action verbs and learning objectives addressed; teaching methods used; materials provided; agenda adjustments and rationale if any]

Group Discussion Themes: [De-identified summary of common questions, barriers, and themes discussed] (Never attribute statements to identifiable individuals.)

General Return Precautions: [Condition-relevant warning signs reviewed with the group; individualized precautions appear in Individual Patient Component below]

Individual Patient Component

Chief Concern: [One-line statement linking visit to program focus and this patient's needs]

Interval History: [Concise update since last visit: symptom changes and pertinent negatives; treatment adherence and barriers; self-monitoring data; interval events such as ER visits or medication changes] (If key data are unavailable, state what is missing and why.)

Participation: [Attendance status if notable; engagement level; key questions asked or teach-back completed by this patient only]

Objective:

• [Vitals with source noted if patient-reported]
• [Focused exam findings if performed] (If no individual exam, state reason such as "visit focused on counseling and medication management.")
• [Pertinent labs, imaging, or self-monitoring data reviewed today]

Assessment:

• [Problem 1]: [Current status with brief clinical reasoning and supporting data relevant to today's decisions]
• [Problem 2]: [Include only problems addressed today]

(List problems in order of clinical priority. Do not carry forward problems not addressed today.)

Plan:

• [Problem 1]: [Medication actions; diagnostics ordered; referrals; individualized self-management instructions] (Include shared decision-making details when treatment options were discussed.)
• [Problem 2]: [As above, only if addressed today]

Patient-Specific Goals: [Patient-centered, measurable goal with timeline and method of tracking; barriers and alternative plans if discussed] (Use patient's own words when possible, e.g., "Goal (patient-stated): 'Walk 20 minutes after dinner 4 days/week.'")

Follow-up and Return Precautions: [Timing and modality of next visit; what will be reassessed; individualized return precautions based on this patient's risk profile, including where to seek care and when]

Administrative/Billing Support

(Include only if needed for billing documentation; keep separate from clinical narrative.)

• Time: [Total group time]; [Individual face-to-face time] (Document non-overlapping times for group vs individual services.)
• Medical Decision-Making: [Straightforward / Low / Moderate / High] (Or specify if time-based billing used.)
• Codes: [E/M code for individual component]; [Group education code if applicable]
• Attestations: [Group consent confirmed; group education and individual E/M were distinct and non-overlapping; other required attestations as applicable]