Chronic care
Chronic disease follow-up template
A problem-oriented review note for long-term conditions, built around control markers, adherence, complication screening and an explicit titration decision.
Best used for
- Diabetes reviews
- Hypertension clinics
- Asthma and COPD reviews
- Long-term condition follow-up
Template structure
Each section shows what to document and a worked clinical example.
List the active long-term conditions with their duration, then the interval history including symptoms, exacerbations and hospital contact.
Example
Type 2 diabetes (8 years), hypertension (5 years). No hypoglycaemic episodes, no visual change, no foot symptoms. No admissions since last review.
Current and previous values for the relevant markers so the trend is visible, plus honest adherence assessment and barriers.
Example
HbA1c 7.8% (was 8.6% six months ago). Home BP average 136/82. Reports taking metformin twice daily, occasionally misses the evening dose when working late.
State which screening is due, which was performed, and the results — retinal, renal, foot, lipid and cardiovascular risk as applicable.
Example
Retinal screening up to date, no retinopathy. Foot examination today: pulses present, monofilament sensation intact. eGFR 82, urine ACR 1.4. Lipids: LDL 2.4 on atorvastatin.
Medication changes with the target they aim at, lifestyle actions agreed with the patient, and the next review interval.
Example
Increase metformin to 1 g twice daily targeting HbA1c below 7%. Continue atorvastatin 20 mg. Agreed to add two 30-minute walks per week. Repeat HbA1c and review in three months.
Documentation tips
- Show the previous value alongside the current one — trend is the clinical signal.
- State the target each medication change is aiming at, not just the new dose.
- Record the specific self-management goal the patient agreed to, in their terms.
Frequently asked questions
- What should a chronic disease review always cover?
- Control markers with their trend, adherence and barriers, complication screening status, medication titration, and the next review interval.
- How often should long-term conditions be reviewed?
- It depends on control and condition — commonly three to six months when titrating, and annually once stable.
- Can ScribeMDPro pull previous values automatically?
- Values from previous ScribeMDPro consultations appear in the clinical timeline; values held only in your EMR are entered during review.
- Does this template suit asthma and COPD reviews?
- Yes. Substitute peak flow, spirometry, exacerbation frequency and inhaler technique for the diabetes-specific markers.
More templates
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