Chronic condition follow-up
United States | Family medicine

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

INTERVAL HISTORY
Conditions addressed today: [ ]
Changes since the previous visit: [ ]
Patient priorities and functional impact: [ ]
Medication use, response, adverse effects and access barriers: [ ]

FINDINGS
Home readings with dates, source and units: [ ]
Vitals measured today, with units: [ ]
Relevant examination findings: [ ]
Results reviewed with dates: [ ]

PROBLEM-BASED ASSESSMENT AND PLAN
Condition and current status: [ ]
Evidence supporting the assessment: [ ]
Treatment decisions and rationale: [ ]
Monitoring, orders and agreed goals: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]