Headings
Interval history · Home readings · Medications and adherence · Side effects · Blood pressure today · Examination · Assessment · Plan
When to use it
Use this when a visit is mainly about blood pressure control, such as a titration check after a dose change or a routine review. It puts home readings beside the office reading and gives side effects their own line, which is where most regimen changes start. It is narrower than a chronic disease follow-up and skips the diabetes screening items.
Example
Fictional example
Interval history
D.A., 51. Started amlodipine 10 mg 8 weeks ago. Cut salt at home. No chest pain or headaches.
Home readings
Average 138/86 over 14 days, morning readings highest.
Medications and adherence
Amlodipine 10 mg daily. Takes it every day.
Side effects
Ankle swelling by evening, worse in hot weather.
Blood pressure today
142/88 seated, repeat 140/86.
Examination
Trace pitting edema both ankles. Heart regular, no murmur. Lungs clear.
Assessment
Hypertension not at goal. Amlodipine edema.
Plan
Reduce amlodipine to 5 mg. Add losartan 50 mg daily. Basic metabolic panel in 2 weeks. Send home readings in 4 weeks.