CHRONIC 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]