Thyroid Disorder Follow-Up Note (Hypothyroidism/Hashimoto)

Date: [Encounter date]

Patient: [Full name]

DOB: [DOB]

Provider: [Provider name, credentials]

Reason for Visit: [Follow-up for hypothyroidism / Hashimoto thyroiditis / central hypothyroidism]

Interval History

[Narrative summary integrating: current diagnosis context (primary vs central; Hashimoto status); current levothyroxine dose and formulation with start date; most recent TSH and FT4 with collection date and whether at goal; interval symptom changes (hypothyroid-type and over-replacement symptoms); medication adherence pattern including actual timing relative to food/coffee, consistency, and missed doses; weight trend since last visit; interval events affecting thyroid requirements (pregnancy status with gestational age or postpartum interval; new interacting medications or supplements such as calcium, iron, PPIs, biotin; GI issues suggesting malabsorption).] (Write as a single cohesive paragraph. Document actual administration routine, not intended routine. If information is unavailable, state "not available at time of visit.")

Objective

Vitals: [BP, HR, weight, BMI, temp as obtained]

Exam: [Pertinent findings: general appearance; thyroid size/tenderness/nodules; cardiac rate/rhythm; skin and hair changes; neurologic findings as examined] (For telehealth, note exam limitations.)

Labs Reviewed: [TSH and FT4 with values, units, reference ranges, collection dates, and trend vs prior] (Note context affecting interpretation if relevant: timing of levothyroxine relative to blood draw, recent biotin use, pregnancy trimester-specific targets. If labs drawn but results pending, document explicitly.)

Assessment

(List each active thyroid problem with current status and supporting evidence. If symptoms and labs are discordant, document possible explanations. For central hypothyroidism, note that TSH is not reliable and FT4 guides titration.)

• [Primary hypothyroidism / Central hypothyroidism / Hashimoto thyroiditis]: [controlled / at goal / improving / worsening] — [Supporting evidence: TSH/FT4 trend, key symptoms, adherence pattern, relevant interacting factors] (Include discordance analysis only if symptom-lab mismatch present.)
• [Additional thyroid problem if addressed]: [Status] — [Supporting evidence] (Include only if applicable.)

Plan

(For each problem, document medication decisions with explicit dosing and rationale, then monitoring and follow-up.)

• Medication: [Continue / Increase / Decrease] levothyroxine [formulation] [dose in mcg] [frequency]. (If changing: prior dose [X mcg], rationale linked to TSH/FT4 trend and clinical context.)
• Administration counseling: [Empty stomach with water; wait 30-60 min before food/coffee; separate from calcium/iron/PPIs by 4 hours; consistent timing]
• Monitoring: [TSH and FT4] in [6-8 weeks if dose/administration change / 6-12 months if stable]. Results via [patient portal / phone / follow-up visit].
• Pregnancy-specific: [TSH target, increased monitoring frequency, gestational age] (Include only if pregnant or postpartum.)
• Pediatric-specific: [Growth monitoring interval] (Include only if pediatric patient.)
• Follow-up: Return in [timeframe] or sooner for [palpitations / chest pain / severe fatigue / other urgent symptoms].