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Chronic care follow-up template
Designed for return visits managing several chronic conditions at once—hypertension, diabetes, lipids, CKD, and more—so each problem gets status, data, and next steps without a vague SOAP dump.
Template content
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Chronic Care Follow-Up Note Visit Context - Interval since last visit and reason for today’s chronic care appointment. - Patient goals and barriers (cost, access, adherence, social determinants) as discussed. Interval History - Symptom changes, acute illness, ED/hospitalizations, and specialist visits since last encounter. - Home monitoring data (BP, glucose, weight, symptom logs) if reviewed. Medications & Adherence - Current regimen with doses; missed doses, tolerability, and recent changes. - OTC/supplements and pharmacy barriers if discussed. Data Reviewed - Labs, imaging, outside records, and care-gap reminders reviewed today. Exam - Vital signs, weight/BMI, and focused exam relevant to active chronic conditions. Problem-Based Assessment & Plan For each active chronic problem (e.g., HTN, T2DM, HLD, CKD, HF, COPD, obesity): - Status (controlled / not at goal / worsening) with brief reasoning. - Key data supporting status. - Plan: medication adjustments, monitoring, lifestyle counseling, referrals, and timing of next labs/visit. Preventive / Care Gaps - Overdue screenings, immunizations, or care-coordination items addressed today. Patient Education & Shared Decisions - Counseling provided; patient understanding and preferences noted. Follow-Up - Return interval, PRN criteria, and care team coordination.
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
- Problem-based layout matches how chronic care visits are actually run.
- Keeps home readings, adherence, and goal progress visible across visits.
- Supports multi-morbidity without burying the plan under a single narrative.
- Pairs well with longitudinal context in Wavo between quarterly visits.
- 1Multi-problem chronic disease visits
- 2Internal medicine and family medicine follow-ups
- 3Diabetes, hypertension, and cardiometabolic clinics
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.
Visit Context 3-month chronic care follow-up for hypertension, type 2 diabetes, and hyperlipidemia. Patient wants help getting fasting glucose under 140. Interval / Home Data Home BP averages 128–134 / 78–84. Fasting glucose typically 130–155. No ED visits. Adherent to metformin and lisinopril; occasionally misses statin when traveling. Exam / Data BP 132/80, HR 72, BMI 31.2. A1c 7.4% (was 7.8%). LDL 118. Cr stable. Feet inspect without ulceration. Assessment & Plan 1) Hypertension — at goal on lisinopril 20 mg daily; continue; home BP log. 2) Type 2 diabetes — improving but not at A1c <7%; continue metformin 1000 mg BID; reinforce carb timing; consider GLP-1 discussion next visit if A1c remains elevated. 3) Hyperlipidemia — not at LDL goal; reinforce nightly atorvastatin; repeat lipid panel in 3 months. Follow-Up Return in 3 months with labs beforehand. Call sooner for persistent BP >150 systolic or symptomatic hypoglycemia.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
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