Sleep Medicine Evaluation Note (Restless Legs Syndrome/PLMD)

Encounter Date: [Date]

Encounter Type: [new / established]; [in-person / telehealth]

Referring Clinician and Reason for Referral: [Referring clinician name, specialty; reason for referral] (Only include if applicable)

Data Sources Reviewed: [Prior sleep studies / Outside labs and notes / Internal chart review / PDMP / Patient-reported data] (List all that apply with dates when available)

(Use explicit status labels throughout: Met / Not Met / Uncertain; Denied; Unknown; Not assessed; Pending. Do not imply completion of elements not assessed.)

Chief Complaint

[Reason for visit in one line, optionally including patient's own words]

History of Present Illness

[Brief summary of presenting problem including context, duration, key symptoms, and primary impact on sleep and daytime function]

RLS Diagnostic Criteria

(Include this subsection when RLS is suspected. If evaluation is for PLMD without RLS features, document that RLS symptoms were Denied and omit criteria below.)

• 1) Urge to move legs with uncomfortable sensations: [Met / Not Met / Uncertain]. [Patient description of urge and sensations, intensity, body parts involved]
• 2) Onset or worsening during rest/inactivity: [Met / Not Met / Uncertain]. [Typical contexts such as sitting, lying down, long travel]
• 3) Relief with movement: [Met / Not Met / Uncertain]. [Type of movement, degree and rapidity of relief, duration of benefit]
• 4) Evening/night predominance: [Met / Not Met / Uncertain]. [Time-of-day pattern, circadian variation]
• 5) Not solely accounted for by another condition: [Met / Not Met / Uncertain]. [Rationale for excluding mimics]

Considered mimics and differentials: [Nocturnal leg cramps / Arthritis or positional discomfort / Peripheral neuropathic pain / Venous stasis / Akathisia / Myofascial pain / Radiculopathy / Other] (Document presence or absence with reasoning)

(If PLMD evaluation only: RLS symptoms [Denied / Unknown / Not assessed])

Symptom Characterization

• Anatomic distribution: [legs / arms / other]; [unilateral / bilateral]; [proximal / distal]
• Sensory descriptors: [Patient's terms for sensations]
• Temporal pattern: Frequency [nights per week]; typical onset time [clock time or relation to rest]; duration [minutes or hours]; course [intermittent / chronic persistent]
• Triggers: [Sedentary activities / prolonged sitting / travel / other]
• Relievers: [Walking / stretching / massage / heat or cold / medications / other]
• Sleep impact: Sleep latency [minutes]; awakenings [number per night]; total sleep time [hours]; [bed partner observations]
• Daytime impact: [Sleepiness / fatigue / cognitive effects / mood / functional limitations]

Severity Assessment

• IRLS Score: [Score] (Date: [date]) (If not obtained: Previous score [value] on [date] / Not assessed)
• Narrative severity: [mild / moderate / severe] (Anchored to frequency, sleep disruption, and daytime impairment)

PLMS Screening

• Bed partner report of rhythmic leg jerks: [Present / Denied / Unknown / No bed partner]
• Unexplained awakenings or restless sleep: [Present / Denied / Unknown] (Include frequency and pattern if present)

Exacerbating Factors and Contributors

• Substances: Caffeine [amount and timing / Denied]; Alcohol [use and timing / Denied]; Nicotine [use / Denied]
• Medications potentially worsening symptoms: [Sedating antihistamines / SSRIs or SNRIs / antidopaminergic agents / mirtazapine / lithium / other] (List agent, dose, temporal association with symptoms)
• Comorbid sleep disorders: [Untreated OSA / Insufficient sleep / Circadian disorder / None identified]
• Medical associations: [Iron deficiency / Anemia / CKD or ESRD / Pregnancy / Neuropathy / Diabetes / None identified]
• Family history of RLS: [Present / Denied / Unknown] (If present: relation and age at onset)

Prior Evaluation and Treatment

• Prior diagnoses: [Diagnosis, clinician, date / None / Unknown]
• Prior sleep study: [Date, PLMI, PLM arousal index, AHI if applicable / None / Unknown]
• Prior iron studies: [Ferritin, TSAT with dates / None / Unknown]
• Prior treatments and responses:
  • Iron therapy: [Oral or IV formulation, dose, response / None tried]
  • Alpha-2-delta ligands: [Agent, dose, response, reason discontinued / None tried]
  • Dopaminergic agents: [Agent, dose, response, reason discontinued / None tried]
  • Opioids: [Agent, dose, response / None tried / Not applicable]
  • Non-pharmacologic measures: [Sleep schedule, stretching, exercise, other] and response

Augmentation and Impulse Control Screen

(Include only if dopaminergic therapy exposure is current or prior; otherwise omit this subsection)

• Earlier daily symptom onset than baseline: [Present / Denied / Unknown]
• Shorter latency to symptoms at rest: [Present / Denied / Unknown]
• Increased intensity requiring dose escalation: [Present / Denied / Unknown]
• Spread to other body parts: [Present / Denied / Unknown]
• Shorter duration of medication benefit: [Present / Denied / Unknown]
• Impulse control symptoms: [Present / Denied / Unknown] (If present: gambling, shopping, hypersexuality, other)

Sleep History

• Schedule: Bedtime [time]; wake time [time]; [regular / variable]
• Sleep latency: [Minutes]
• Awakenings: [Number per night; causes]
• Total sleep time: [Hours]
• OSA symptoms: [Snoring / witnessed apneas / gasping / morning headaches / Denied / Not assessed] (Include if clinically relevant)
• Safety concerns: Drowsy driving or occupational risk [Present / Denied]

Past Medical History

• CKD or ESRD: [Present with stage / Denied / Unknown]
• Iron deficiency or anemia: [Present with etiology / Denied / Unknown]
• GI malabsorption or bariatric surgery: [Present / Denied / Unknown]
• Neuropathy: [Present / Denied / Unknown]
• Diabetes: [Present / Denied / Unknown]
• Pregnancy status: [Pregnant / Not pregnant / Not applicable]
• Psychiatric history: [Depression / Anxiety / Other / Denied]
• Family history: [RLS / Movement disorders / Iron disorders in first-degree relatives / Denied / Unknown]

Medications

• Current medications: [List with dose and timing] (Flag agents known to worsen RLS)
• Evening medication timing relative to symptom onset: [Details]
• Prior RLS medications: [Agent and reason discontinued / None]
• Iron supplements: [Formulation, dose, schedule, adherence, tolerability / None]
• Allergies: [List, especially iron formulations / NKDA]

Review of Systems

(Targeted to differential diagnosis; omit systems not assessed)

• Neurologic: Neuropathic symptoms, weakness, paresthesias [Present / Denied / Not assessed]
• Musculoskeletal: Cramps, arthritis [Present / Denied / Not assessed]
• Vascular: Edema, claudication, varicosities [Present / Denied / Not assessed]
• Psychiatric: Anxiety, akathisia features [Present / Denied / Not assessed]
• GI: Occult bleeding signs, malabsorption symptoms [Present / Denied / Not assessed]

Physical Examination

(Include only elements performed; if telehealth, note limitations)

• Vitals: BP [value]; HR [value]; Weight [value]; BMI [value]
• General: [Appearance, alertness, distress level]
• Neurologic: [Mental status, strength, sensation, reflexes, gait]
• Extremities: [Edema, tenderness, skin changes, varicosities]

Diagnostic Data

Iron Studies

• Ferritin: [Value] ng/mL (Date: [date]; [fasting morning / non-fasting / Unknown])
• Serum iron: [Value] mcg/dL
• TIBC or transferrin: [Value]
• Transferrin saturation: [Value]%
• Interpretation: [Iron replete / Iron deficient / Indeterminate] (Note if inflammatory confounders suspected)
• Status: [Reviewed / Pending / Not assessed]

Sleep Testing

• PSG: [Date / Not available]
• PLMI: [Value] per hour; PLM arousal index: [Value] per hour
• OSA indices: AHI [value]; ODI [value]; SpO2 nadir [value]% (If applicable)
• Other findings: [Brief summary]
• Testing plan: [PSG ordered / Outside study retrieval requested / Not indicated]

Additional Labs

• CBC: Hgb [value]; Hct [value]; MCV [value] (Date: [date])
• Renal function: Cr [value]; eGFR [value] (Date: [date])
• Other: [B12, folate, TSH, CRP as obtained]
• Status: [Reviewed / Pending / Not assessed]

Assessment

(List problems in decreasing clinical importance with status, key supporting data, and clinical reasoning)

1) Restless Legs Syndrome

Status: [New / Established]; [Worsening / Stable / Improving]. Course: [Intermittent / Chronic persistent]. Severity: [IRLS score or mild / moderate / severe].

• Diagnostic criteria: [All 5 criteria met / Criteria not fully met with explanation]
• Iron status: [Iron replete / Iron deficient / Indeterminate]; [inflammatory confounders if applicable]
• Contributors identified: [Substances, medications, comorbid sleep disorders, medical conditions]
• Augmentation status: [Present / Absent / Not applicable] (If dopaminergic exposure)
• Impulse control: [Concern present / No concern / Not applicable]

2) Periodic Limb Movement Disorder

(Include only if PLMD suspected or confirmed)

Status: [New / Established]; [Worsening / Stable / Improving].

• PSG criteria: PLMI [value] per hour with [sleep disturbance / daytime impairment documented / not demonstrated]
• Exclusion of other causes: RLS [excluded / contributing]; OSA [excluded / contributing]; medications [excluded / contributing]; insufficient sleep [excluded / contributing]
• Clinical significance: [PLMS driving symptoms, supports PLMD diagnosis / Incidental PLMS, no independent diagnosis warranted]

Additional Problems

• Iron deficiency: [Status and key data] (If present)
• Comorbid sleep disorders: [OSA, insomnia, circadian disorder with status] (If present)
• Other relevant conditions: [Neuropathy, CKD, pregnancy with pertinent details] (If applicable)

Plan

RLS Management

• Exacerbating factors: [Caffeine, alcohol, nicotine counseling]; [Medication review with recommendations to avoid, switch, or coordinate with prescribers]; [Comorbid sleep disorder management]
• Iron evaluation and replacement: Labs [ordered / reviewed]. Action plan: [Oral iron regimen if ferritin below threshold / IV iron if oral intolerant or malabsorption / Repletion not indicated]. Recheck iron studies in [timeframe].
• Non-pharmacologic interventions: [Regular sleep schedule / Sleep hygiene / Stretching or massage / Hot or cold application / Moderate exercise / Mental alerting activities during sedentary periods]
• Pharmacotherapy: [Not indicated at this time / Initiating therapy as below]
  • Alpha-2-delta ligand: [Agent] [dose] [timing relative to symptom onset]; titration [plan]; counsel on [dizziness, sedation, weight gain]
  • Dopaminergic agent: [Agent] [dose] [timing]; counsel on [augmentation risk, impulse control disorders, nausea]; monitoring plan [symptom timing and spread]
  • Refractory or augmentation strategy: [Combination therapy / Dose reduction and switch / Low-dose opioid with risk mitigation] (If applicable)
• Safety counseling: [Drowsy driving and machinery precautions reviewed / Not applicable]

PLMD Management

(Include only if PLMD diagnosed)

• Clinical correlation: PLMS [confirmed as symptom driver / likely incidental]
• Treatment goal: [Reduce PLMS-related arousals / Improve sleep continuity / Address bed partner disturbance / Reassurance only]
• Plan: [Address primary sleep disorder first / Pharmacotherapy with agent and dosing / Observation with reassurance]

Monitoring and Follow-up

• Parameters to track: [Severity rating, symptom onset timing, medication adverse effects, sleep outcomes, iron indices]
• Follow-up: [Timeframe]; return sooner if [worsening symptoms or adverse effects]

Patient Education and Shared Decision-Making

• Diagnosis and pathophysiology explained: [RLS / PLMD]; importance of iron optimization discussed
• Treatment options reviewed including risks, benefits, and alternatives; patient preferences: [Documented]
• Resources provided: [Yes / No]

Orders and Coordination

• Labs: [Iron studies, CBC, other] [Ordered / Not indicated]
• Sleep testing: [PSG ordered / Outside study retrieval / Not indicated]
• Prescriptions: [New medications or dose changes with instructions / None]
• Referrals: [Hematology, nephrology, neurology, other / None] (If applicable)
• Care coordination: [Communication sent to PCP or psychiatry regarding medication contributors / Not applicable]
• PDMP: [Reviewed / Not applicable]