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Heart failure clinic visit template
Designed for heart failure clinic encounters where volume assessment, guideline-directed medical therapy, labs, and device or remote-monitoring data drive the visit.
Template content
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Heart Failure Clinic Visit Note Interval History - HF symptoms: dyspnea, orthopnea, PND, edema, abdominal bloating, fatigue, palpitations, syncope. - NYHA class and activity tolerance compared with prior visit. - Diet (sodium/fluid), daily weights, and recent weight trend. - Hospitalizations, ED visits, IV diuretics, or remote-monitoring alerts since last visit. Volume & Congestion Assessment - Patient-reported congestion and home weight changes. - Clinician assessment of volume status (euvolemic / hypervolemic / hypovolemic). GDMT & Medications - Current HF regimen by class (ARNI/ACEI/ARB, beta-blocker, MRA, SGLT2i, loop diuretic, ivabradine, digoxin, hydralazine/nitrate as applicable). - Adherence, tolerability, hypotension, hyperkalemia, renal limitations, and cost barriers. - Anticoagulation/antiplatelet therapy if relevant. Data Reviewed - Labs (BMP, Mag, BNP/NT-proBNP, CBC as relevant), ECG, echo (EF/phenotype), right-heart cath if available. - Device interrogation or remote pulmonary artery / impedance data when discussed. Exam - Vitals including orthostatics if done; weight. - JVP, S3/murmurs, lung findings, edema, perfusion. Assessment - HF phenotype and stage/class (e.g., HFrEF NYHA II–III), volume status, and GDMT completeness. - Contributing factors (ischemia, arrhythmia, valvular disease, nonadherence, infection). Plan - Diuretic adjustment and volume management instructions. - GDMT initiation/titration with monitoring (labs, BP, symptoms). - Testing, referrals (advanced HF, EP, rehab, palliative), education, and follow-up timing. - Red-flag return precautions.
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
- Puts NYHA class, volume status, and GDMT gaps front and center.
- Supports HFrEF and HFpEF workflows with shared structure.
- Captures barriers (cost, hypotension, renal function) that block titration.
- Pairs well with longitudinal patient context across frequent HF touchpoints.
- 1Outpatient heart failure clinic visits
- 2GDMT titration and post-discharge HF follow-ups
- 3Device clinic visits with HF management overlap
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 68-year-old with HFrEF (EF 28%) after recent admission for volume overload. Home weights up 3 lb over 4 days. Mild orthopnea returned; no chest pain. NYHA III today (was II at last clinic visit). Reports missing 2 days of furosemide while traveling. Volume Assessment Mildly volume overloaded: +3 lb from dry weight, trace-1+ pretibial edema, JVP ~10 cm. GDMT Sacubitril/valsartan 49/51 BID, carvedilol 12.5 BID, empagliflozin 10 mg, spironolactone 25 mg, furosemide 40 mg daily. BP limits further ARNI uptitration at home (SBPs 95–100). Data Reviewed Cr 1.3 (baseline 1.2), K 4.6, NT-proBNP 1850. ICD interrogation last month: no VT; 98% BiV pacing. Exam BP 102/64 seated, HR 70. Soft S3, basilar crackles, 1+ edema. Assessment HFrEF NYHA III with mild congestion after diuretic nonadherence. GDMT otherwise optimized pending BP. Plan Increase furosemide to 40 mg BID for 3 days then return to 40 mg daily if weight back to dry weight. Strict 2 g sodium diet; daily weights. Recheck BMP in 1 week. Hold ARNI uptitration until euvolemic and SBP consistently >100. Follow up in 2 weeks; call for +5 lb or worsening dyspnea.
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