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Interval History Note Visit Context - Time since last visit and reason for today’s return. - Patient agenda for today. Interval History - Changes since last encounter: symptoms, function, adherence, side effects, ED/hospitalizations, specialist input, and life events affecting care. - Home monitoring trends if reviewed (BP, glucose, weight, symptom diaries). - Explicitly note what is unchanged/stable when relevant. Medications (Delta Only) - New, stopped, or changed medications; adherence barriers. Data Since Last Visit - Labs, imaging, and outside records reviewed with brief interpretation. Focused Exam - Vitals and exam elements needed for today’s decisions. Assessment & Plan - Problem-based updates: status vs last visit and next steps. - Education and shared decisions. Follow-Up - Interval to next visit and PRN criteria.
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Visit types and clinicians who use this format
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Context Return visit 6 weeks after starting sertraline 50 mg for mixed anxiety/depression; also HTN follow-up. Interval History Mood and sleep improved; panic less frequent. Mild first-week nausea resolved. No SI/HI. Home BP 124–130 systolic. No ED visits. Continues weekly therapy. Meds / Data Sertraline 50 mg daily adherent; lisinopril 10 mg unchanged. PHQ-9 8 (was 14); GAD-7 7 (was 13). Exam BP 128/78, euthymic affect, linear thought; no tremor. A/P 1) Anxiety/depression — good partial response; continue sertraline 50 mg; consider increase to 75 mg at next visit if plateau; therapy continued. 2) Hypertension — at goal; continue lisinopril; labs at annual visit. Follow-Up 8 weeks or sooner for worsening mood, SI, or BP symptoms. Crisis resources reinforced.
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Paste this content into My Templates, or start from a specialty-generated template and edit the sections.
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
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