Thyroid Function Disorder Follow-Up Note

Date: [Date]

Patient: [Patient name or identifier]

Provider: [Provider name, credentials]

Visit Type: [in-person / telehealth]

Reason for Visit: [Reason for visit]

Interval History

[Orienting summary: Diagnosis being followed (hypothyroidism or hyperthyroidism with etiology if known), time since last visit, and overall trajectory: [improved / worsened / stable]. Include relevant interval events such as intercurrent illness, weight change, or new/stopped medications affecting thyroid (e.g., amiodarone, lithium, estrogen).]

Thyroid medication regimen

• [Current thyroid medication(s), dose(s), and formulation] (If not obtained, enter "Unknown")
• [Administration timing relative to meals and day-to-day consistency] (If not obtained, enter "Unknown")
• [Missed dose pattern or recent changes in routine] (If not obtained, enter "Unknown")
• For levothyroxine: [Concurrent agents that may interfere with absorption (calcium, iron, antacids, PPIs, prenatal vitamins) and timing relative to dose] (If not obtained, enter "Unknown"); Biotin supplement use: [yes / no / unknown]
• For antithyroid drugs: [Current dose and frequency]; Warning symptom screen (fever/sore throat, rash, jaundice, dark urine, abdominal pain): [absent / present—specify / unknown]

Pregnancy/lactation status: [pregnant / postpartum / lactating / planning pregnancy / not pregnant / not assessed] (Do not infer; document explicitly or note "not assessed" if not discussed.)

Symptoms: [Pertinent positives and negatives relevant to the disorder managed—for hypothyroidism: fatigue, weight change, cold intolerance, constipation, mood/cognition, menstrual changes; for hyperthyroidism: palpitations, tremor, anxiety, heat intolerance, weight loss, eye symptoms if Graves' disease] (Document only findings explicitly reported.)

Objective

Vitals: [Weight with trend if available], [HR], [BP], [Temperature if on antithyroid drugs or infection concern]

Exam: [Pertinent findings only: thyroid size/nodules/tenderness/bruit; tremor; reflexes; eye findings if Graves' concerns; cardiac rhythm if relevant]

Labs: (If multiple results available, present as trend below. If no new labs, state explicitly: "No new thyroid labs since [date].")

Date	TSH	Free T4	T3 (if obtained)	Dose at draw	Adherence/timing notes
[Date]	[Value]	[Value]	[Value / not obtained]	[Medication and dose]	[e.g., missed doses, took with food, biotin exposure]

[Other relevant results currently influencing management: TRAb/TSI, imaging, post-RAI/thyroidectomy details] (Only include if relevant to current visit.)

Assessment

(For each thyroid problem addressed, state diagnosis, current status, key supporting evidence from symptoms and lab trends, and relevant clinical modifiers. When labs and symptoms are discordant, document the discrepancy and plausible cause.)

[Problem #]: [Diagnosis name]

• Status: [controlled / uncontrolled / improving / stable / worsening]
• Supporting evidence: [Summary of labs and symptoms supporting status]
• Modifiers: [pregnancy, cardiac disease, osteoporosis risk, central hypothyroidism, post-RAI/thyroidectomy, etc.] (Only include if applicable.)
• Discordance: [If labs and symptoms disagree, document suspected reason and plan to clarify; otherwise omit this line.]

Plan

(Organize by problem. Link changes to data in Assessment. If critical information is missing, document what is unknown and how it will be addressed.)

[Problem #]: [Diagnosis name]

• Therapeutic goal: [Target TSH range, or Free T4 target for central hypothyroidism/early hyperthyroidism treatment, individualized to patient]
• Medication: [Current dose] → [new dose / continue]; [rationale linked to labs/symptoms]; [administration instructions including timing]. (Note: ~4–6 weeks to steady state for levothyroxine; more frequent monitoring if pregnant or high-risk.)
• Monitoring: [Labs to obtain and timing; include biotin hold ≥48 hours before labs if relevant]
• Safety counseling: [For antithyroid drugs: stop and contact clinic if fever/sore throat, jaundice, or severe abdominal pain; obtain urgent CBC and LFTs if symptoms arise] [For thyroid hormone in at-risk patients: overtreatment risks including AF and bone loss]
• Follow-up: [Interval and method of results communication]

Information gaps: [Unknown items critical to care and plan to obtain, or "None"]