Sports Medicine Follow-Up Visit Note

Date: [Date]

Visit Type: Follow-up

Provider: [Provider name and credentials]

Patient: [Patient identifier per local policy]

Injury Side: [R / L / bilateral]

Sport/Position/Level: [Sport, position, competition level if relevant to RTS planning]

Key Dates: [Injury date; surgery date; injection date; imaging date as applicable]

Chief Complaint

[Single-line follow-up focus stating body part/problem, intervention being reassessed, and current goals] (May include brief patient quotation if it clarifies current concerns.)

Interval History

[Orientation sentence stating who is being seen, for what problem, interval since last visit, and what intervention/event occurred between visits.]

• Interval course: [Symptom trajectory: improved / worsened / unchanged; timing patterns; flares; new symptoms; current severity with consistent scale]
• Functional change: [What the patient can do now vs prior visit including ADLs, work, sleep, and sport-specific tasks]
• Treatment exposure/response: [PT attendance and HEP adherence; medications tried with response; bracing/taping/orthotics; activity modifications; injection details if applicable]
• Adverse effects/complications: [Side effects or complications from treatment] (Omit if none.)
• New injuries or red flags: [Reinjury events or red-flag symptoms such as instability, locking, progressive weakness, fever, night pain, neurovascular changes] (Omit if none.)
• Sport context: [Current training load; recent load changes; upcoming events; athlete's stated RTS goals and timeline] (Include only if relevant to RTS decisions.)

(Use "Unknown" when patient cannot provide information; "Not available" when outside records not received; "Not assessed today" when topic not addressed. Do not include placeholder normal findings.)

Objective

Vitals: [Vital signs if obtained] (Omit line entirely if not obtained.)

Exam: (Document only maneuvers actually performed. Compare to prior visit when possible.)

• Inspection: [Alignment, swelling/effusion, atrophy, ecchymosis, gait/posture] — [improved / unchanged / worsened vs prior]
• Palpation: [Tenderness location and quality; crepitus] — [comparison to prior]
• Range of motion: [AROM/PROM by plane in degrees with contralateral comparison] — [change vs prior]
• Strength: [Grades or dynamometry with side-to-side comparison] — [change vs prior]
• Special tests: [Tests actually performed and results]
• Neurovascular: [Sensation, reflexes, pulses] (Include only if assessed.)
• Functional/sport-specific testing: [Tasks performed; tolerance; movement quality] — [change vs prior] (Include only if performed.)

Data Reviewed: [Imaging, labs, PT/AT notes, or consultant notes reviewed today with dates and key findings; note if images personally reviewed vs report only] (Omit if none reviewed.)

Assessment

(List active problems by priority with laterality and chronicity. For each, state status since last visit tied to measurable change.)

[Problem 1]: [Diagnosis with laterality and chronicity]

[improved / worsened / unchanged / resolved / recurrent] — [measurable change in pain, function, or exam findings]. [Key supporting data.] (Include differential only if uncertainty affects plan.)

[Problem 2]: [Diagnosis with laterality and chronicity]

(Add additional problems as needed.)

Plan

[Problem 1]: Plan

• Diagnostics: [Test(s) ordered with clinical question and urgency] (Omit if none.)
• Rehabilitation: [PT plan focus areas, frequency/duration, progression strategy; HEP priorities]
• Medications: [Medication, dose, route, frequency, duration; precautions] (Omit if none.)
• Bracing/DME: [Type, fit, wear schedule] (Omit if none.)
• Procedures/Injections: [Indication, options, risks/benefits discussed] (Omit if not applicable.)
• Activity modification: [Allowed vs prohibited activities; load management targets; cross-training options]
• Return-to-sport progression:
  • Current stage: [rehab only / modified training / non-contact practice / full participation with restrictions / full participation]
  • Criteria to progress: [Objective benchmarks: symptom thresholds, ROM and strength targets vs contralateral, functional test goals]
  • Actions before next visit: [Specific drills/exercises; monitoring plan]
  • Risk discussion: [Residual risks; signs to stop; contingency if symptoms recur]
  • Stakeholder coordination: [Roles among clinician, AT, coach, athlete/family] (Include only if applicable.)
• Follow-up: [Timeframe for reassessment; what should prompt earlier return]

[Problem 2]: Plan

(Repeat structure for additional problems.)

Procedure Note

(Include only if a procedure was performed today; otherwise omit entire section.)

• Procedure: [Name; site; laterality]
• Indication: [Clinical indication]
• Consent: [Risks, benefits, alternatives discussed; consent obtained]
• Technique: [Preparation; approach and guidance; needle/equipment; agents with doses]
• Tolerance/Complications: [Patient tolerance; immediate complications or none]
• Post-procedure instructions: [Aftercare, activity restrictions, warning signs]