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Internal medicine progress note template
A clinic-ready IM progress structure for adult patients with layered medical issues—interval events, data synthesis, and a problem-based assessment that reads like a specialist ambulatory note.
Template content
Copy or download, then paste into Wavo under My Templates.
Internal Medicine Ambulatory Progress Note Reason for Visit - Follow-up focus and patient agenda for today. Interval History - Changes since last visit: symptoms, function, hospitalizations/ED visits, specialist encounters, and adherence. - New medications, OTC agents, and adverse effects. Past History (Pertinent Updates) - Updates to medical, surgical, family, and social history as discussed. Medications & Allergies - Active medication list with adherence notes; allergies/reactions. Data Reviewed - Labs, imaging, cardiac studies, PFTs, outside records, and care-gap alerts reviewed today with interpretation. Exam - Vital signs and exam pertinent to active problems. Assessment & Plan (Problem-Based) For each active problem: - Impression and current status. - Supporting data and differential as needed. - Diagnostics, therapeutics, monitoring parameters, counseling, and referrals. - Coordination with specialists and pending items. Preventive Care - Age-appropriate preventive items addressed or deferred today. Disposition / Follow-Up - Return interval, contingency plans, and patient instructions.
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
- Balances narrative interval history with a disciplined problem list.
- Makes specialist coordination and pending studies easy to track.
- Fits longer IM slots without forcing an ED or hospital note shape.
- Works as a default ambulatory template for general internal medicine panels.
- 1Adult internal medicine clinic follow-ups
- 2Complex multi-morbidity ambulatory visits
- 3Post-hospitalization primary IM check-ins
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.
Reason for Visit Follow-up after recent hospitalization for CHF exacerbation; also review CKD and anemia labs. Interval History Discharged 12 days ago after diuresis; now euvolemic at rest, DOE with one flight of stairs. Taking furosemide as directed; daily weights stable ±1 lb. No chest pain. Cardiology follow-up scheduled next week. Data Reviewed Discharge summary reviewed. BMP today: Cr 1.5 (baseline 1.3–1.4), K 4.1. Hb 10.8. BNP downtrending per hospital course. Echo EF 35% (known). Exam BP 108/68, HR 74, SpO2 97% RA, weight 182 lb (down 8 lb from admission peak). Lungs clear; trace pretibial edema; JVP not elevated. Assessment & Plan 1) HFrEF — compensated post-exacerbation; continue GDMT (sacubitril/valsartan, carvedilol, spironolactone, SGLT2i) and furosemide; daily weights; low-sodium counseling reinforced; keep cardiology appointment. 2) CKD stage 3 — mild Cr rise post-diuresis; hold further up-titration of ACEi/ARNI pending next BMP in 1–2 weeks. 3) Anemia — stable; iron studies ordered; GI workup previously deferred—revisit if Hb declines. Follow-Up Clinic in 2 weeks with BMP; sooner for weight gain >3 lb in 2 days, orthopnea, or chest pain.
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
Start free, paste the template, and see how Wavo documents in your structure.