Primary Care — Follow-up Visit Template

The Follow-up Visit Template is designed for primary care providers conducting routine return visits for established patients. This streamlined template efficiently documents interval history since last visit, medication adherence and response, symptom changes, focused physical examination, assessment of condition status, and treatment plan adjustments. The template supports appropriate billing for established patient visits (CPT 99212-99215) while maintaining documentation efficiency for high-volume follow-up appointments. Key sections include interval history with changes since last visit, medication review with adherence assessment and side effects, symptom tracking and response to treatment, focused physical examination relevant to ongoing conditions, assessment of condition status (improved, stable, worsened), treatment plan adjustments including medication changes, laboratory or imaging follow-up, patient education reinforcement, and scheduling of next appointment. This template balances thoroughness with efficiency, ensuring quality documentation without excessive time burden. Ideal for primary care practices managing chronic conditions, routine follow-ups, medication monitoring visits, and post-procedure follow-up appointments.