Rheumatology Progress Note

Template structure

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

Subjective:
(hyphenated list)
- [Chief complaint or reason for visit]
- [Interval history since last visit, including changes in symptoms, function, or quality of life]
- [Current joint pain, swelling, stiffness (location, duration, severity, timing)]
- [Fatigue, fever, rashes, or other systemic symptoms]
- [Medication adherence, side effects, or changes]
- [Patient-reported outcome measures if applicable]
- [Other concerns or questions from patient]

Objective:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Musculoskeletal exam: joint swelling, tenderness, range of motion, deformities (specify joints and findings)]
- [Skin: rashes, nodules, ulcers]
- [Other relevant systems: e.g., cardiovascular, respiratory, neurological]
- [Laboratory results with units] (e.g., ESR, CRP, CBC, renal/liver function, autoantibodies)
- [Imaging results if available]

Assessment:
(hyphenated list)
- [Primary rheumatologic diagnosis and disease activity assessment]
- [Comorbidities or complications]
- [Response to therapy]
- [Differential diagnosis if relevant]

Plan:
(hyphenated list)
- [Adjustments to medications (name, dose, route, frequency)]
- [Laboratory or imaging investigations ordered]
- [Non-pharmacologic interventions (e.g., physical therapy, exercise, lifestyle advice)]
- [Patient education and counselling]
- [Referrals to other specialties if needed]
- [Follow up interval and monitoring plan]
- [Return precautions]