Headings
Conditions reviewed · Interval history · Medications and adherence · Examination · Results reviewed · Assessment · Plan · Follow-up
When to use it
Use this for a scheduled check on two or more long-term conditions in one visit, such as thyroid disease, high cholesterol or kidney disease. It lists the conditions up front, then ties interval history, adherence and lab trends to a plan for each one. Pick a single-condition template like diabetes or hypertension when one problem is the whole visit.
Example
Fictional example
Conditions reviewed
Hypothyroidism. Hyperlipidemia. Chronic kidney disease stage 3a.
Interval history
P.N., 64. Feels well. Mild fatigue in the afternoons. No weight change or cold intolerance.
Medications and adherence
Levothyroxine 75 mcg daily, taken with coffee. Rosuvastatin 10 mg daily. No missed doses.
Examination
BP 124/78. No thyroid enlargement. No leg edema.
Results reviewed
TSH 6.8. LDL 82. eGFR 54, stable from 56 last year. Urine albumin to creatinine ratio 22.
Assessment
Hypothyroidism undertreated, likely from taking dose with coffee. Lipids at goal. Kidney function stable.
Plan
Take levothyroxine 30 minutes before breakfast. Keep same dose. Avoid NSAIDs.
Follow-up
Repeat TSH in 6 weeks. Visit in 6 months with kidney panel.