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Inflammatory arthritis disease-activity visit template
Built for treat-to-target inflammatory arthritis visits—RA, PsA, and related diseases—where joint counts, activity scores, therapy response, and escalation decisions need a consistent structure.
Template content
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Inflammatory Arthritis Disease-Activity Visit Diagnosis / Phenotype - Confirmed or working diagnosis (RA, PsA, SpA-related peripheral arthritis, etc.) and serology/phenotype notes. - Extra-articular or domain involvement (skin, nails, entheses, axial, uveitis, IBD) as relevant. Interval History - Joint pain/swelling pattern, morning stiffness duration, flares, and functional impact (work, ADLs). - Skin/enthesitis/axial symptoms if PsA/SpA spectrum. - Current therapy adherence, steroid bursts, NSAID use, and infections. Disease Activity Assessment - Tender/swollen joint counts or targeted joint findings as performed. - Composite scores (CDAI, DAS28, DAPSA, etc.) or RAPID3/HAQ if used—record only measured values. - Patient and physician global assessments if obtained. Exam - Focused MSK exam; skin/nails/entheses as indicated; cardiopulmonary if relevant to therapy risk. Data Reviewed - CRP/ESR, safety labs, imaging for progression/erosions, and outside records. Assessment - Disease activity category and trajectory (improved / stable / worsened). - Whether treat-to-target goal is met. - Toxicity or barriers to escalation. Plan - Maintain vs escalate/switch DMARD/biologic/tsDMARD with rationale. - Steroid bridge/taper if used; PT/OT, lifestyle, and comorbidity management. - Monitoring labs, imaging, and follow-up interval; flare plan.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Centers disease activity and treat-to-target decisions rather than a generic SOAP dump.
- Supports RA and PsA phenotypes including skin, enthesitis, and axial symptoms when present.
- Keeps steroid burden and DMARD/biologic changes explicit.
- Pairs with biologic monitoring when the visit is primarily safety-focused.
- 1RA and PsA disease-activity visits
- 2Treat-to-target rheumatology follow-ups
- 3Inflammatory oligo-/polyarthritis reassessments
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Diagnosis / Phenotype Seropositive RA (RF/CCP+), no extra-articular ILD known. Target: low disease activity / remission. Interval History Morning stiffness 75 minutes; difficulty opening jars. Two steroid Medrol packs from urgent care in 6 weeks. On methotrexate 20 mg weekly; declining self-injection previously, now open to biologic. No active infection. Disease Activity SJC 6, TJC 9; patient global 6/10; physician global 5/10; CDAI moderate-high activity. CRP 1.9. Exam Synovitis wrists and multiple MCPs/PIPs bilaterally; no nodules; lungs clear. Assessment RA not at treat-to-target goal on MTX monotherapy; recurrent steroid rescue—escalate therapy. Plan Continue MTX; initiate TNF inhibitor after updated TB/hepatitis screen (ordered). Short prednisone 10 mg × 7 days then 5 mg × 7 days bridge. Discussed infection risk and vaccine status. Labs before start; nurse injection teaching. Follow up 8 weeks after biologic start or sooner for fever/infection or severe flare.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
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3. Review and sign
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Put this template to work on your next visit
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