Rheumatology Note

Template structure

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

Diagnosis:
[Primary rheumatological diagnosis]  
[Date diagnosed (if mentioned)]  

Clinical Phenotype
[Relevant clinical phenotype including how diagnosis was made, relevant labs that informed diagnosis]  

Relevant medications:  
[Current medications, including any disease-modifying antirheumatic drugs (DMARDs), biologic agents, pain management medications, supplements, etc. (mention if available)]  
[Prior medications, listing reasons for cessation such as intolerance or inefficacy]  
[Allergies, including allergies to medications, particularly NSAIDs or biologics, etc. (mention if available)]  

Notable comorbidities:  
[Past medical and surgical history, highlighting any previous rheumatologic diagnoses, treatments, surgeries, hospitalizations, outcomes, etc. (mention if available)]  

Interval History:
[Change(s) since last appointment, including change in symptoms, impact of new therapies/change in therapies or interventions. Reason(s) for consultation, including specific rheumatologic concerns or symptoms such as joint pain, stiffness, swelling, systemic symptoms like fatigue, fever, weight loss, skin rashes, dry eyes or mouth, etc. (mention if available) (Write in full sentences)]  
[Detailed history of the presenting complaint(s), including onset, duration, severity, pattern of joint involvement (symmetrical/asymmetrical), morning stiffness, aggravating/alleviating factors, associated systemic symptoms, any previous treatments (e.g., NSAIDs, DMARDs, biologics) and responses, etc. (mention if available)]  

[Mention any interval changes in medical or surgical history (if discussed)]  
[Mention any recent infections (if discussed)]  
[Vaccination/immunization status (if discussed)]  
[Review of systems (write in full sentences, pertinent positives and negatives; state otherwise negative after completing this)]  

Physical exam:
[Vitals (mention if available)]  
[Physical examination findings, in following format: On examination, (insert name) appears well. Conjunctiva are clear. Normal salivary pooling. No visible nasal or oral ulcerations. HR (if mentioned) RRR. S1+S2 without murmurs, rubs or gallops. Lung fields are clear without rales or wheeze. There is *** alopecia, rash, Raynaud’s. On musculoskeletal examination ***.]  
[Emphasis on musculoskeletal examination including joint inspection, palpation, assessment of range of motion, identification of synovitis, bursitis, tenosynovitis, etc. (mention if available) (write in full sentences)]  
[Skin examination for rheumatologic markers, nail changes, etc. (mention only if applicable and if available)]  

Investigations:
[Investigations with results, including laboratory tests, imaging studies, including any prior investigations provided in context (mention if available) (write in full sentences)]  

Assessment:  
[Name has Rheumatologic Issue or Condition, and comment on progress/whether doing well or not].  
[Assessment, including the likely diagnosis and rationale based on subjective and objective findings (mention if available)]  
[Differential diagnosis (include only if explicitly mentioned)]  
[Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning (mention if available)]  
[Medical treatment planned, including details, for example, the type of DMARDs, biologics, pain management strategies, dosage, expected outcomes, potential side effects, etc. (mention if applicable and available)]  
[Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc. (mention only if applicable and available)]  
[Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc. (mention if applicable and available)]  
[Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans, etc. (mention only if applicable and available)]  
[Mention any referrals (mention if applicable and available)]  

[Additional Rheumatologic Issues or Conditions]  
[Follow the same structure as above for each additional issue or condition identified (if applicable and if available)]  

[Patient education on the diagnosed condition, including explanation of the disease process, potential complications, and the importance of treatment adherence, etc. (mention only if applicable and available)]  
[Instructions for symptom monitoring, including joint swelling, pain levels, and any new symptoms indicating disease progression or adverse effects of treatment (mention only if applicable and if available)]  
[Importance of vaccination/immunization while on immunosuppressive medication (if mentioned)]  
[Any specific patient or family concerns addressed during the consultation (mention only if applicable and if available)]  

Plan:
(hyphenated list)
- [Summary of plan in bullet points]  

Procedure:
[Joint injection] (if relevant)  

Follow up: [Follow up scheduled]