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Neurology Follow-Up Note Interval History - Neurologic symptoms since last visit: seizures, headache, weakness, sensory change, tremor, gait, cognition, vision, speech, pain, autonomic symptoms. - Frequency/severity/duration trends and functional impact (work, driving, ADLs, falls). - Triggers, adherence, lifestyle factors, and intercurrent illness or hospitalizations. Treatment Response - Current neurologic medications/devices with doses. - Benefit, adverse effects, adherence barriers, and recent dose or regimen changes. Exam - Focused neurologic exam with attention to changes from prior visit. - Relevant scales (e.g., NIHSS, UPDRS subset, MoCA, MIDAS) if performed. Data Reviewed - Interval imaging, EEG, labs, EMG, or outside neurology records discussed today. Assessment - Updated neurologic diagnosis/status and trajectory (improved / stable / worsened). Plan - Medication adjustments, further testing, safety counseling (driving, falls, seizure first aid), referrals, and follow-up interval.
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 interval neurologic change and treatment tolerability.
- Keeps scales and testing interpretation visible across visits.
- Works for epilepsy, migraine, neuromuscular, movement, and general neurology clinics.
- Pairs cleanly with Wavo patient context for longitudinal specialty care.
- 1Outpatient neurology medication follow-ups
- 2Post-hospitalization neurology check-ins
- 3Chronic neurologic disease monitoring visits
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.
Interval History Patient with localization-related epilepsy returns for 3-month follow-up. Two focal aware seizures last month lasting ~30 seconds each; previously seizure-free for 5 months. No GTC events. Sleep-deprived week before breakthrough. Driving currently restricted per prior counseling. Treatment Response Lamotrigine 200 mg BID. Missed 1 evening dose during travel before first breakthrough. Mild tremor; no rash. Considering dose increase. Exam Alert, fluent. CN intact. Mild fine postural tremor. Strength, sensation, gait unchanged. Data Reviewed EEG 8 months ago: left temporal sharp waves. MRI brain stable MTS left. Assessment Localization-related epilepsy with recent breakthrough in setting of missed doses and sleep deprivation; otherwise previously well controlled. Plan Increase lamotrigine to 250 mg BID. Reinforce adherence and sleep hygiene. Continue driving restriction until 6 months seizure-free per local regulations discussed. Follow up in 3 months or sooner for clusters. Refill provided.
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