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How to Document an Established-Patient Follow-Up Visit

Introduction

Follow the guidelines below when documenting an established-patient follow-up visit.

Open the patient’s appointment in DrChrono and go to the Note section. Select History of Present Illness (HPI) to begin documenting the visit.

The fields in the HPI are arranged to guide both your documentation and the clinical flow of the visit. Complete them in order.

Important Information (H)

The Important Information (H) field contains information the provider should review before conducting the visit. The (H) indicates that the field is hidden and does not appear in the progress note.

Select all applicable options from the dropdown. Available options include:

  • Patient does not know that they were adopted.
  • Patient prefers male pronouns.
  • Patient prefers female pronouns.
  • Patient prefers gender-neutral pronouns.
  • Patient prefers to be seen alone, without the guardian present.
  • Guardian prefers to provide history without the patient present.
  • Patient does not want the guardian to know about the following information.

These selections serve as reminders for future visits. They help the provider remember how the patient prefers to be addressed, how the interview should be conducted, and whether any sensitive information or confidentiality considerations require additional caution.

Personal Notes (H)

The Personal Notes (H) field is also hidden and does not appear in the progress note.

Use this field for personal reminders that may help you when you see the patient again.

Sources of Information

The Sources of Information field carries forward the individuals who were present and provided information during the previous visit.

Update this field at every visit so that it accurately reflects who was present and provided information during the current visit.

Select the applicable sources from the dropdown. If none of the available options accurately describes a person who provided information, select The Following:. Then identify the person and their relationship to the patient in the free-text field titled If Info Was Obtained From Someone Else, List Here.

Tasks for the First Established-Patient Visit:

At the patient’s first follow-up visit after the new patient evaluation:

  1. Turn off the New Patient toggle.
  2. Turn on the Established Patient toggle.

These steps only need to be completed at the first established-patient visit. Once the Established Patient toggle has been turned on, it should remain on for all subsequent visits.

Problem Areas

The first field under the Established Patient toggle is Problem Areas.

This is a multiselect field containing all problem areas available in the DrChrono History of Present Illness (HPI), listed in alphabetical order. Select every problem area that is currently active for the patient. 

Medication Changes Made On or Since the Last Visit

Enter a brief summary of:

  • Medication changes made during the previous appointment.
  • Any additional medication changes made between the previous and current appointments.

Medication changes may occur between visits when a patient or guardian contacts MindWeal by telephone or Secure Chat and the treatment plan is adjusted in response.

Before seeing the patient:

  1. Review the Plan section of the previous progress note to identify the medication changes made during that appointment.
  2. Review the Communication section of the patient’s chart to determine whether any additional changes were made afterward by telephone or Secure Chat.
  3. Enter a brief summary of all medication changes made on or since the previous visit. You do not need to document doses, titration schedules, or other details in this field.

Examples:

  • Focalin XR was increased.
  • Clonidine ER was changed to clonidine IR.
  • Zoloft was cross-titrated to Lexapro.

Medication Compliance

After reviewing and summarizing the medication changes made on or since the previous visit, determine whether the patient followed the prescribed medication plan.

Ask whether the patient has been taking the medications regularly and as prescribed. Then select the option that most accurately describes the patient’s medication use.

Medication Compliance Options

  • Has been taking all medications as prescribed: Select when the patient has consistently followed the entire medication plan.
  • Has been taking prescribed medications intermittently: Select when the patient has taken the medications inconsistently, such as only on certain days or with frequent missed doses.
  • Has been partially compliant with medications: Select when the patient has followed only part of the medication plan.
  • Has been non-compliant with medications: Select when the patient has not been taking the prescribed medications.
  • Has been taking all medications except one or two medications: Select when the patient has followed most of the medication plan but has not taken one or more specific medications.

Medication Compliance Comments

Use the Medication Compliance Comments field whenever additional information is needed to explain the selected response. Document:

  • Which medications were missed, stopped, or taken differently than prescribed.
  • How frequently the medications were being taken.
  • When the patient’s medication use changed.
  • The reason the patient or guardian gives for not following the prescribed plan.

If the patient reports that a medication was stopped or taken inconsistently because of side effects, document the side effects in the following Medication Side Effects section rather than duplicating the details here.

Medication Side Effects

The next field asks whether the patient has experienced any medication side effects.

  • Select No when no medication side effects are reported.
  • Select Yes when one or more medication side effects are reported.

When Yes is selected, document the relevant details in the Side Effects Comments field, including:

  • The specific side effect.
  • The medication believed to be causing it.
  • When the side effect began.
  • Its severity and frequency.
  • Whether it has improved, persisted, or worsened.

Provider Pitfalls

(1) Keep History Separate From Clinical Assessment

The fields discussed in this section are part of the History and Physical (H&P). Document what the patient, guardian, or another source of information reports—not your clinical interpretation of that information. 

For example:

  • H&P: Parent reports that the patient misses clonidine approximately three nights per week.
  • Medication Treatment Plan: Take clonidine every night as prescribed. Inconsistent adherence is likely contributing to the continued sleep difficulty.

The first statement documents the history provided. The second reflects the provider’s clinical assessment of the effect of medication noncompliance.

(2) Do Not Enter Today’s Treatment Plan in the Medication Changes Field

Medication Changes Made On or Since the Last Visit is a historical field. Document only changes made during the previous visit or between visits. Any medication change decided during today’s visit belongs in today’s Medication Treatment Plan.

For example, if Focalin XR was increased at the previous visit and you decide today to increase Lexapro:

  • Medication Changes Made On or Since the Last Visit: Focalin XR was increased.
  • Today’s Medication Treatment Plan: Increase Lexapro.

How These Fields Structure the Beginning of the Visit: 

These fields are not merely documentation requirements. Their sequence is designed to show you how to prepare for, begin, and think through an established-patient visit.

Before the visit, review the previous note and subsequent communications so that you understand what was changed. Then begin the visit by briefly summarizing those changes and asking whether the patient followed the plan.

For example:

“Our last visit was about one month ago. During that visit, Focalin XR was increased and clonidine IR was changed to clonidine ER. Have you been taking all of the medications regularly?”

Based on the response:

  1. Document whether the patient has been taking the medications as prescribed.
  2. If the medications were not taken as prescribed, document the reason provided.
  3. Ask whether the patient experienced any medication side effects.
  4. Document the reported side effects.
  5. Proceed to evaluate the benefits of treatment and the patient’s current symptoms under the applicable problem areas in the HPI.

This creates a structured and clinically logical beginning to the visit:

  • What medication changes were made on and since last visit?
  • Did the patient follow the updated plan?
  • Were there any side effects?
  • What benefit did the patient experience?

Following this sequence prepares you for the visit, keeps the interview focused from the beginning, and provides the clinical context needed to evaluate each active problem area and formulate the next treatment plan.