Endocrinology Note: Structure and Sections
Endocrinology, Diabetes & Metabolism encounter note. Notermed's built-in Endocrinology Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record. In the app the format is listed as Endocrinologist Notes.
What the Endocrinology Note contains
14 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint (CC)
- A short reason for the visit
- For example diabetes follow-up, thyroid nodule, hyperparathyroidism
- 2
History of Present Illness (HPI)
- Reason for referral or follow-up
- Glycemic control and its trend
- Hypoglycemia and hyperglycemia: frequency, timing, awareness
- Polyuria, polydipsia, weight change, fatigue
- Heat or cold intolerance, palpitations, tremor
- Adherence, diet, and activity
- Home glucose or CGM data the clinician reviewed aloud
- 3
Past Medical History (PMHx)
- Relevant medical history, where provided
- 4
Past Surgical History (PSHx)
- Prior surgery such as thyroidectomy or bariatric surgery
- 5
Family History (FHx)
- Diabetes, thyroid disease, endocrine tumours in the family
- 6
Social History
- Smoking status and alcohol
- Diet pattern and physical activity
- 7
Review of Systems (ROS)
- Only the systems raised, with the findings actually stated
- 8
Medications
- Insulin regimen, with any titration stated
- Oral agents, GLP-1 or SGLT2, thyroid replacement
- Medications from an attached list
- 9
Allergies
- Allergies as stated
- No known allergies only when someone said so
- 10
Vitals
- BP and HR
- Height, weight, BMI, weight trend
- Waist circumference
- 11
Physical Exam
- By system: GEN, NECK and thyroid, CV, RESP
- ABD, EXT, SKIN, NEURO
- Diabetic foot and monofilament examination
- Only findings actually stated or dictated
- 12
Results / Diagnostics
- HbA1c and glucose, reported with any prior value
- CGM metrics such as time-in-range and GMI
- Thyroid panel: TSH, free T4 and T3, antibodies
- Lipid panel
- Renal function and urine albumin to creatinine
- Vitamin D, calcium, PTH
- Cortisol and ACTH
- DEXA T-score, thyroid ultrasound or other imaging impression
- 13
Assessment
- A problem list of the diagnoses the clinician stated
- ICD-10 codes flagged for billing verification
- Severity or control status, only where the clinician stated it
- 14
Plan
- Grouped by problem, numbered
- Diabetes: insulin or oral agent change, GLP-1 or SGLT2 start
- Diabetes: glucose or CGM monitoring, HbA1c interval
- Diabetes: education or nutrition referral, foot and eye screening
- Thyroid: levothyroxine dose change, TSH recheck interval
- Thyroid: ultrasound or FNA, endocrine surgery referral
- Bone: vitamin D and calcium repletion, bisphosphonate, repeat DEXA
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Endocrinology Note
What sections does the endocrinology note contain?
Fourteen, from Chief Complaint and History of Present Illness through the medical, surgical, family and social histories, Review of Systems, Medications, Allergies, Vitals, Physical Exam and Results and Diagnostics, to the Assessment and Plan.
Does the note record HbA1c and CGM data?
Where they were reviewed in the visit. Results and Diagnostics reports HbA1c and glucose with any prior value, CGM metrics such as time in range and GMI, the thyroid panel, the lipid panel, renal function and urine albumin to creatinine, vitamin D, calcium and PTH, cortisol and ACTH, and a DEXA T-score or an imaging impression.
Is the insulin regimen recorded?
Yes. Medications records the insulin regimen with any titration stated, oral agents, a GLP-1 or SGLT2 agent, thyroid replacement, and medications from an attached list.
Who decides what the plan says?
You do. The plan is grouped by problem and numbered and records the changes made in the visit, and the note is a draft until you review it and sign it.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Endocrinology Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.