Rheumatology Clinical Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Rheumatology Consultation Template

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Detailed description of presenting symptoms, including onset, duration, progression, pattern, and associated features such as pain, swelling, stiffness, fatigue, rash, fever, or other systemic symptoms]
[Relevant prior treatments, response to therapy, and impact on function or quality of life]

Past Medical History:
(hyphenated list)
- [Relevant chronic illnesses, prior rheumatologic diagnoses, surgeries, hospitalizations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include disease-modifying antirheumatic drugs (DMARDs), biologics, NSAIDs, corticosteroids, supplements]

Allergies:
(hyphenated list)
- [Drug allergies and reactions]
- [Other allergies]

Family History:
(hyphenated list)
- [Autoimmune or rheumatologic conditions in first-degree relatives]
- [Other relevant family history]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Functional status: ability to perform activities of daily living, work, exercise]

Review of Systems:
(hyphenated list)
- [General: fever, weight loss, fatigue]
- [Musculoskeletal: joint pain, swelling, stiffness, weakness]
- [Skin: rash, nodules, ulcers]
- [Eyes: redness, pain, vision changes]
- [Cardiopulmonary: chest pain, dyspnea, cough]
- [GI: abdominal pain, diarrhea, oral ulcers]
- [GU: dysuria, hematuria]
- [Neurologic: headache, numbness, weakness]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Musculoskeletal: joint inspection, swelling, tenderness, range of motion, deformities, muscle strength]
- [Skin: rashes, nodules, ulcers]
- [Eyes: conjunctivitis, scleritis, uveitis]
- [Other systems as relevant]

Investigations:
(hyphenated list)
- [Laboratory results: CBC, ESR, CRP, RF, anti-CCP, ANA, ENA panel, uric acid, HLA typing, etc.]
- [Imaging: X-rays, ultrasound, MRI, CT]
- [Other relevant tests]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary rheumatologic diagnosis or concern]

#) [Assessment as a numbered item for each active issue]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Treatment plan: medication changes, initiation, discontinuation]
- [Non-pharmacologic management: physical therapy, occupational therapy, lifestyle modifications]
- [Counselling discussion: disease education, medication risks/benefits, prognosis]
- [Referrals sent: other specialties, allied health]
- [Follow up plan: timing, location, specific goals]
- [Return precautions]

Thank you for allowing me to participate in this patient care 
Dictated using voice recognition software and therefore may contain typographical errors