Rheumatology Note: Structure and Sections
Rheumatology specialty visit note with strict evidence rules. Notermed's built-in Rheumatology 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 Rheumatologists Notes.
What the Rheumatology Note contains
12 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint
- The primary reason for the visit, as stated
- 2
History of Present Illness
- Onset, duration, quality, and severity
- The specific joints involved
- Aggravating and alleviating factors
- Associated symptoms and progression
- Morning stiffness duration and gel phenomenon
- Enthesitis and dactylitis
- Raynaud phenomenon and sicca symptoms
- Constitutional symptoms
- 3
Past Medical History
- Prior diagnoses such as RA, SLE, gout, OA, psoriasis
- Surgeries and hospitalizations
- 4
Medications
- Current medications with dose, frequency, and duration
- Grouped as DMARDs, biologics, NSAIDs, steroids where clear
- 5
Allergies
- Drug and environmental allergies, and the reactions
- 6
Social History
- Smoking, alcohol, recreational drugs
- Occupation and living situation
- 7
Family History
- Autoimmune, psoriasis, or rheumatologic conditions in the family
- 8
Review of Systems
- Only the systems discussed, with the findings actually stated
- Skin rashes, alopecia, oral ulcers
- Sicca symptoms, Raynaud phenomenon, eye symptoms
- 9
Physical Examination
- Vital signs and general appearance
- Joint counts, synovitis, crepitus
- Deformities in MCP, PIP, DIP, MTP joints
- Skin examination: malar rash, tophi, psoriasis
- 10
Laboratory & Imaging Results
- Inflammatory markers: ESR, CRP
- Autoantibodies: ANA with pattern, RF, anti-CCP, anti-dsDNA, anti-Sm
- ANCA, HLA-B27, uric acid
- Synovial fluid analysis
- X-ray, ultrasound, or MRI findings and impression
- 11
Assessment
- The clinical impression the clinician stated
- A differential, only where one was verbalized
- A disease-activity score such as DAS28 or CDAI, only where stated
- 12
Plan
- Treatment and medication changes or tapers
- Any glucocorticoid-sparing strategy
- Monitoring labs, such as methotrexate monitoring
- Additional testing and imaging
- Follow-up interval and referrals
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 Rheumatology Note
What sections does the rheumatology note contain?
Twelve, from the Chief Complaint and History of Present Illness through Past Medical History, Medications, Allergies, Social History, Family History, Review of Systems, Physical Examination and Laboratory and Imaging Results, to the Assessment and Plan.
Does the note record a disease-activity score?
Only where one was stated. A score such as DAS28 or CDAI appears in the assessment when the clinician gave it, next to the impression they stated and a differential only where one was verbalized.
What is recorded about the joints?
The history covers the specific joints involved, morning stiffness duration and the gel phenomenon, enthesitis and dactylitis. The examination records joint counts, synovitis and crepitus, and deformities in the MCP, PIP, DIP and MTP joints, as they were described.
Which laboratory results does the note report?
Whatever was reviewed in the visit: inflammatory markers such as ESR and CRP, autoantibodies including ANA with its pattern, RF, anti-CCP, anti-dsDNA and anti-Sm, ANCA, HLA-B27 and uric acid, synovial fluid analysis, and the findings and impression from an X-ray, ultrasound or MRI.
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 Rheumatology 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.