Hypertension follow-up
Internal medicine

Blank documentation outlines. 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
Changes since the previous visit: [ ]
Symptoms reported: [ ]
Medication use as reported, adherence and adverse effects: [ ]
Salt intake, activity, alcohol and other factors discussed: [ ]

BLOOD PRESSURE READINGS
Office readings today, with position, arm and time: [ ]
Repeat readings if taken: [ ]
Home readings reviewed, with device, dates and number of readings: [ ]

FINDINGS
Other vitals measured today, with units: [ ]
Relevant examination findings: [ ]
Laboratory results reviewed with dates: [ ]

ASSESSMENT AND PLAN
Current control and supporting readings: [ ]
Medication decisions and rationale: [ ]
Agreed target and home monitoring plan: [ ]
Orders and counseling provided: [ ]

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