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Biologic / DMARD monitoring visit template
Designed for rheumatology visits focused on biologic, JAK inhibitor, or DMARD monitoring—efficacy, infection risk, labs, TB/hepatitis screening status, and clear continue/hold/switch decisions.
Template content
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Biologic / DMARD Monitoring Visit Therapy Context - Current agent(s), dose, route, frequency, and start date / last administration. - Indication (e.g., RA, PsA, AS, SLE, vasculitis) and concomitant csDMARDs/steroids. Efficacy / Interval History - Disease-activity trend since last visit or last dose. - Flares, functional status, and steroid rescue use. - Adherence and injection/infusion tolerability. Safety Review - Infections (including TB exposure, shingles, UTI, sinus, skin), wounds, dental procedures, planned surgery. - Neurologic symptoms, new heart failure symptoms, malignancy concerns, GI perforation warning signs for relevant agents, thrombosis risk for JAKi as applicable. - Vaccine status and counseling. Labs / Screening - CBC, CMP/LFTs, lipid panel (if JAKi), inflammatory markers as ordered. - TB, hepatitis B/C screening status and need for update. - Drug-specific monitoring (e.g., immunoglobulin for rituximab) if relevant. Exam - Focused MSK/systemic exam as indicated for efficacy and safety. Assessment - Efficacy: controlled / partial / inadequate response. - Safety: cleared to continue vs hold / investigate. - Immunosuppression risk counseling documented. Plan - Continue, dose-adjust, hold, or switch therapy with rationale. - Labs before next dose; antimicrobial or vaccine plan; peri-op hold instructions if upcoming procedure. - Follow-up / next infusion or injection timing.
When to use this template
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Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Separates efficacy from safety/toxicity—the two questions these visits answer.
- Prompts infection, vaccine, TB/hepatitis, and lab checkpoints clinicians expect.
- Documents hold criteria and restart plans for peri-operative or infectious interruptions.
- Works for TNF, IL-17/23, IL-6, rituximab, JAKi, and csDMARD monitoring.
- 1Biologic infusion and injection follow-ups
- 2JAK inhibitor and DMARD safety visits
- 3Pre-therapy restart or hold assessments
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.
Therapy Context Adalimumab 40 mg SC every 14 days for PsA since 2024; methotrexate 15 mg weekly; no chronic steroids. Efficacy Skin nearly clear; morning stiffness 15 minutes; enthesitis improved. One mild knee flare after overuse, resolved with NSAID. Adherent; last injection 6 days ago, no site reaction. Safety No fevers, cough, shingles, or TB exposure. Dental cleaning next month—discussed low risk, no hold needed for stable patient per clinic practice. COVID/flu vaccines up to date; shingles vaccine previously completed. Labs / Screening CBC/CMP normal; CRP 0.3. QuantiFERON negative 11 months ago—repeat at 12 months. HBsAg/anti-HBc previously negative. Assessment PsA well controlled on adalimumab + MTX; no safety barriers to continuation. Plan Continue current regimen. Labs and TB screen at next visit in 3 months. Hold biologic and call clinic for fever with productive cough, shingles, or planned major surgery. Refill adalimumab; MTX continued with folic acid.
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