Each condition, in its own block.
Vero Scribe fills in your follow-up template, problem by problem, from the visit conversation, with the patient’s consent, or from your dictation. You review and edit the draft, then copy it into your EHR.
Chronic Disease Follow-Up Note Template
A chronic disease follow-up note reviews each long-term condition against its target: control, adherence, complication screening, and the plan. Copy the free template, see a diabetes and a COPD example, and check what goes in each part.
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- Word and text downloads
- Two filled examples
Blank chronic disease follow-up note template
FreeCHRONIC DISEASE FOLLOW-UP NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Visit type: [In person, video, or phone] Clinician: [Name, credentials] Conditions reviewed: [Each chronic condition addressed today] INTERVAL HISTORY Since the last review: [Symptoms, flares or exacerbations, emergency or hospital visits, care from other clinicians] Patient's priorities: [What the patient most wants to address today] MEDICATION RECONCILIATION Medication list: [Each drug, dose, and frequency, checked against the pharmacy record] Adherence: [Missed doses, how each is taken, cost or access barriers] Side effects: [Side effects asked about and reported, or none] Changes since the last visit: [Started, stopped, or changed, and by whom] EXAMINATION AND RESULTS Vital signs: [BP, HR, RR, SpO2, weight, BMI] Examination: [Focused findings for each condition] Results: [Latest monitoring tests with dates, and the trend] PROBLEM 1 Condition: [Diagnosis, how long, and the target agreed with the patient] Control: [Measures against the target, such as A1c, home BP average, symptom score, or exacerbations] Complication screening: [Checks due for this condition, such as feet, eyes, and kidneys, with dates and results] Self-management: [Home monitoring, the goal set last time, progress, and the new goal] Plan: [Medication changes with dose, monitoring, referrals, and education] PROBLEM 2 Condition: [Diagnosis, how long, and target] Control: [Measures against the target] Complication screening: [Checks due, with dates and results] Self-management: [Monitoring, goals, and progress] Plan: [Changes, monitoring, referrals, and education] FOLLOW-UP Next review: [When, and which tests to do beforehand] Contact sooner if: [Symptoms or home readings that should prompt a call or visit] Signed: [Clinician name, credentials, date and time]
Use it for
- Diabetes reviews
- Hypertension follow-ups
- COPD and asthma reviews
- Medication reviews
- Kidney disease monitoring
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Chronic disease follow-up: type 2 diabetes and hypertension
Primary care, 3-month review
Interval history
54-year-old man with type 2 diabetes for 6 years and hypertension for 4 years, here for his 3-month review. No emergency visits. No chest pain, breathlessness, foot sores, or change in vision. His priority: loose stools after his evening metformin dose.
Medication reconciliation
Checked against the pharmacy record. Metformin 1000 mg twice daily: skips the evening dose about 4 nights a week because of loose stools. Lisinopril 10 mg daily: takes it every morning; no cough or dizziness. Atorvastatin 40 mg daily: no muscle aches. No over-the-counter drugs or supplements. No changes since the last visit.
Examination and results
BP 146/88, repeat 142/86; HR 76. Weight 94 kg (207 lb), down 1 kg (2 lb); BMI 30.7. Feet: skin intact, no calluses, pedal pulses present, monofilament sensation normal at all sites. Results from last week: A1c 7.9%, from 7.4% 3 months ago. Creatinine 88 µmol/L (1.0 mg/dL), eGFR 85 mL/min/1.73 m², potassium 4.4 mmol/L. Urine albumin-to-creatinine ratio 1.1 mg/mmol (10 mg/g). LDL 1.7 mmol/L (66 mg/dL).
Problem 1: type 2 diabetes
Target A1c 7.0% or below, agreed. Control: above target and rising; home fasting glucose 7.5 to 9.0 mmol/L (135 to 162 mg/dL), in line with the missed evening doses. Complication screening: feet low risk today; retinal exam 2 years ago showed no retinopathy and is now due; kidney function and urine albumin normal; LDL at target on atorvastatin. Self-management: last goal, no sugary drinks, met; new goal, walking 30 minutes on 5 days a week. Plan: switch to extended-release metformin with the evening meal, 1000 mg for 2 weeks, then 2000 mg if tolerated. Discussed adding an SGLT2 inhibitor or a GLP-1 receptor agonist; he prefers to fix the missed doses first. Referred for a retinal exam.
Problem 2: hypertension
Target below 130/80, agreed. Control: above target; home average 144/88 from 14 readings over 7 days on a validated upper-arm cuff, close to the office readings. No side effects. Complication screening: kidney function, potassium, and urine albumin normal, as above. Self-management: cutting down on salt; measures twice daily. Plan: increase lisinopril to 20 mg daily, with creatinine and potassium in 1 to 2 weeks.
Follow-up
Video or phone check in 4 weeks, with a week of home readings. Full review in 3 months, with A1c, creatinine, and potassium the week before. Call the same day for dizziness, fainting, or home readings above 180/110. Call 911 for swelling of the face, lips, or tongue, chest pain, or weakness on one side.
Chronic disease follow-up: COPD
Primary care, 6-month review
Interval history
68-year-old woman with COPD diagnosed 4 years ago, here for her 6-month review. One flare 5 months ago, with more breathlessness and green sputum, treated at urgent care with prednisone and an antibiotic; no hospital stay. Since then, breathless after one flight of stairs and using her rescue inhaler 3 to 4 times a week. Her priority: keeping up with her grandchildren.
Medication reconciliation
Checked against the pharmacy record. Umeclidinium/vilanterol 62.5/25 mcg, 1 inhalation once daily: misses it when she stays away from home. Albuterol (salbutamol) inhaler, 2 puffs as needed, 3 to 4 times a week. No side effects. No home oxygen. No changes since the prednisone course.
Examination and results
BP 128/76, HR 84, RR 18, SpO2 94% on room air. Weight 61 kg (134 lb), stable. Speaks in full sentences. Chest: prolonged expiration, no wheeze or crackles. No ankle swelling. COPD Assessment Test (CAT) score 16, from 18 at the last review. Spirometry 2 years ago: post-bronchodilator FEV1/FVC 0.62, FEV1 58% predicted. Inhaler technique: dry powder inhaler used correctly; with the rescue inhaler she presses before breathing in and doesn’t hold her breath.
Problem 1: COPD
Moderate airflow obstruction. Target agreed: no flares, and enough breath to walk with her grandchildren. Control: partial; CAT 16, rescue inhaler 3 to 4 times a week, 1 moderate flare in the past year. Complication screening: SpO2 94%, weight stable, PHQ-2 score 0. Former smoker, 40 pack-years, quit 3 years ago: eligible for lung cancer screening by current criteria. Self-management: no written action plan before today. Plan: continue umeclidinium/vilanterol daily, with a phone alarm as a reminder. Spacer given for the rescue inhaler; technique taught back correctly. Influenza vaccine given today; pneumococcal vaccine 2 years ago; other vaccines reviewed per current guidance. Referred to pulmonary rehabilitation and for low-dose CT lung cancer screening. Written action plan completed: when to use more rescue inhaler, when to call the clinic, and when to call 911. If flares continue, review treatment against current COPD guidelines, including a blood eosinophil count.
Follow-up
Review in 3 months, once pulmonary rehabilitation has started; bring all inhalers and the spacer. Call the clinic the same day if breathlessness, sputum amount, or sputum color is worse for more than a day. Call 911 for breathlessness at rest, chest pain, blue lips, or confusion.
What goes in each part.
Interval history
What has happened since the last review, and what the patient wants from this one.
- New or worse symptoms, flares, or exacerbations
- Emergency visits or hospital stays
- Changes made by specialists or other clinicians
- The patient’s own priorities for the visit
Avoid: Running through your checklist before asking what matters most to the patient today.
Medication reconciliation
What the patient actually takes, compared with the record and the pharmacy list.
- Each drug, dose, and frequency, as actually taken
- Missed doses, and the reasons for them
- Side effects, asked about directly
- Cost or access problems
- Changes since the last visit, and who made them
Avoid: Reading the list back and asking “any changes?” instead of asking how each medication is taken.
Examination and results
The measurements and tests that show how each condition is doing.
- Vital signs and weight, with the trend
- Focused findings for each condition
- Monitoring results with dates, such as A1c, lipids, kidney function, or spirometry
- Skills observed, such as inhaler technique
Avoid: Quoting a result without its date, which can make an old value look current.
Problem 1
One block per condition, repeated for each one you review, so targets, results, and changes stay separate.
- The target agreed with the patient
- Control against that target, with the trend
- Complication screening due, with the date of the last check
- Self-management: home readings, last goal, progress, new goal
- The plan, with any dose change and the reason for it
Avoid: Writing “stable” without saying what is stable: the A1c, the home readings, the symptoms, or the flares.
Follow-up
When the next review is, what has to happen first, and when to get in touch sooner.
- The interval to the next review
- Tests to do beforehand, so results are ready
- Home readings to bring
- Readings or symptoms that need a call before then
Avoid: Booking the review without ordering the tests that should come before it.
Common mistakes, and how to avoid them.
Adding a drug before checking adherence
Poor control often comes from missed doses or side effects. Ask how each medication is taken before you intensify treatment.
Losing track of complication screening
Record the date and result of the last foot, eye, and kidney checks at every diabetes review, so it’s clear what is due.
Home readings without context
Note the device, how many readings over how many days, and the average. A single reading recalled from memory can mislead.
Targets nobody agreed
Targets vary with age, other conditions, and the patient’s wishes. Record the one you agreed, and why, especially when it differs from the usual.
Missing changes made elsewhere
Specialists, hospital stays, and pharmacists change medications between visits. Reconcile the list against the pharmacy record each time.
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Frequently asked questions.
What goes in a chronic disease follow-up note?
For each condition: control against the target, adherence and side effects, the complication screening that is due, self-management goals, and the plan. Add a medication reconciliation and the date of the next review.
How do you write a diabetes follow-up note?
Record the A1c and its trend, home glucose readings, adherence, and side effects, then the foot, eye, and kidney checks with their dates. Close with the plan and the target you agreed. The first example above is one.
How often should chronic conditions be reviewed?
It depends on the condition and how well it is controlled. Many are reviewed about every 3 months while treatment is changing, and less often once targets are met; follow current guidelines for each condition.
Should each condition have its own assessment and plan?
Yes. A block per condition keeps targets, results, and changes from blurring together, and makes it quicker to see what is due at the next review.
What is medication reconciliation?
Comparing what the patient actually takes with the record and the pharmacy list, then resolving the differences. It catches changes made elsewhere, and doses taken differently from how they were prescribed.
Is this chronic disease follow-up note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
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