Progress / Follow-up Note: Structure and Sections
Return visit: interval history and updated plan. Notermed's built-in Progress / Follow-up 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.
What the Progress / Follow-up Note contains
7 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Interval History
- Course since the last visit
- New events between visits
- Adherence to treatment
- 2
Current Symptoms / Response to Treatment
- Symptoms as they stand today
- Response to the treatment in place
- 3
Medications
- Current medications
- Anything started, stopped, or adjusted
- 4
Focused Review of Systems
- General: fever, chills, night sweats, weight change, fatigue
- HEENT: congestion, post-nasal drip, hoarseness, headache
- Cardiovascular: chest pain, palpitations, syncope, leg edema
- Pulmonary and respiratory: cough, dyspnea, wheeze, sputum, hemoptysis
- Sleep: snoring, witnessed apneas, daytime sleepiness, CPAP or BiPAP use
- Gastrointestinal: nausea, vomiting, abdominal pain, reflux
- Genitourinary: frequency, urgency, dysuria, hematuria
- Gynaecological: menstrual irregularity, pelvic pain, pregnancy status
- Musculoskeletal: joint pain, muscle weakness, back pain, stiffness
- Skin: rashes, lesions, itching, cyanosis, clubbing
- Allergy and immunologic: allergies and reactions, allergic rhinitis, triggers
- Endocrine: thyroid symptoms, diabetes, blood sugar control
- Hematologic and oncologic: bruising, bleeding, clots, malignancy history
- Central nervous system: dizziness, seizures, numbness, memory changes
- Psychiatric: mood, anxiety, depression, sleep disturbance, panic attacks
- 5
Physical Examination
- Vital signs including oxygen saturation
- Focused examination findings
- 6
Assessment
- Each known or active problem
- Whether it is improved, stable, or worsening
- 7
Plan
- Treatment adjustments or continuation
- Tests ordered
- Referrals
- Follow-up
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 Progress / Follow-up Note
What does the progress note cover?
Seven sections: Interval History, Current Symptoms and Response to Treatment, Medications, Focused Review of Systems, Physical Examination, Assessment and Plan. The interval history takes the course since the last visit, new events between visits, and adherence to treatment.
How does the note know what has changed since the last visit?
From this visit. The draft is built only from what was said in the room, so the interval history is whatever the two of you covered about the time between visits: the course since the last one, new events, and adherence to treatment.
Does every heading appear on every return visit?
No. A section nobody said anything about is left out rather than padded, so a short follow-up produces a short note instead of a full form with empty headings in it.
Does the assessment say whether a problem is improving?
Where the clinician said so. The assessment lists each known or active problem and whether it is improved, stable or worsening, in the terms used during the visit.
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 Progress / Follow-up 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.