Follow-up visit note template

Most outpatient work is follow-up, yet many clinicians write follow-ups with a first-visit layout and bury the one thing that matters: has it worked. This template puts the change since the last visit first. Below it: a filled invented example, common slips, and how the ClearPass Follow-up structure produces this note.

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How a follow-up note differs from a first visit

At a first visit you gather background. At a follow-up the background already exists; the question is whether the plan from last time did what you hoped. So the note should open with the reason for review and the response to treatment, then adherence and side effects, then today's findings and new results, and close with a decision: continue, adjust, stop, or investigate further.

Keep background short. One line that points to the original diagnosis is enough. The space goes to the comparison with last time, stated with numbers where you have them.

Blank follow-up template

Template

FOLLOW-UP VISIT
Reason for review: [condition / result / treatment check]
Last seen: [interval] - plan then:

Since last visit:
  Symptoms: better / same / worse, details:
  Events (admissions, new diagnoses):
Current treatment:
  Adherence:
  Side effects:

Today:
  Observations:
  Examination:
  Results since last visit (with previous value):

Assessment: [condition] - responding / partial / not responding
Plan: continue / change / stop / investigate
Patient's understanding and agreement:
Next review: [interval, with what test first]

Copy and adapt. Headings are a common layout, not a regulatory standard.

Filled example: iron deficiency on oral iron

Example

Reason for review: response to oral iron, 8 weeks.
Last seen: 8 weeks ago with fatigue; Hb 98 g/L, ferritin 6. Heavy periods identified as the likely cause. Started ferrous sulfate 200 mg once daily (clinician's decision). Referred to gynaecology.

Since last visit: energy much better, climbing stairs without stopping. Periods still heavy, gynaecology appointment in 3 weeks.
Adherence: taking most days, missed about one dose a week.
Side effects: dark stools, mild constipation, managing with more fibre.

Today: HR 74, BP 112/70. Not pale.
Results: Hb 118 (from 98), ferritin 22 (from 6).

Assessment: iron deficiency anaemia responding to oral iron; stores still low. Ongoing loss from heavy menstrual bleeding.
Plan: continue ferrous sulfate for a further 3 months to replenish stores. Keep gynaecology appointment. Repeat Hb and ferritin in 3 months.
Patient understands and agrees.
Next review: 3 months, after blood test.

Invented example for illustration. Not a real patient.

Slips to watch for

Restating the whole history and leaving the response to treatment for the last line.
Writing improved without saying compared with what. Give the previous value next to today's.
Not asking or not documenting adherence before changing a dose.
Forgetting outstanding actions from last time, such as a pending referral or test.
Ending without a review interval and what should happen before it.

How ClearPass writes a follow-up note

Choose Follow-up as the note structure. It leads with what has changed since the last visit, then current treatment and adherence, then today's findings and plan, the same order as the template above. Tap Transcribe, confirm the patient agrees, talk as you normally would, and tap Stop; the draft appears in English, Concise or Detailed as you chose.

Two features help specifically with follow-ups. History can be grouped by the patient label you gave a note, so you can open the last visit before the next one starts; notes stay on your device and are not synced. And the numbers check marks any value in the draft that was not said in the transcript, which matters when a note compares old and new results. You still review and correct every draft. If a result came on paper, photograph it and the values are read into the note. For patients with several conditions, the problem list note template may suit better.

What ClearPass does not do

It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
It is not a medical device and does not make clinical decisions. It is a documentation aid.
It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Can I use SOAP for follow-up visits?

Yes. Many clinicians do. The Follow-up layout simply puts the change since last visit first, which is what the next reader looks for.

Does ClearPass remember the previous visit automatically?

Not in the sense of reading it into the new note. Previous notes are in History on your device, grouped by patient label if you use labels, and you can open them before the visit.

What if the follow-up is by phone or video?

The same structure works. Transcribe runs in the browser; state in the note that the review was remote and what could not be examined.

What does ClearPass cost?

The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.

Try it on your next clinic day

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