Comprehensive Patient Note Components for Hypertension Management
A comprehensive patient note for a patient with hypertension should include standardized blood pressure measurements, cardiovascular risk assessment, physical examination findings, laboratory results, treatment plan with specific medication details, and follow-up instructions. 1, 2
Patient History Documentation
Chief Complaint and Subjective Information
- Document presenting symptoms (headache, visual disturbances, chest pain, dyspnea, neurological symptoms) 1
- Record duration of hypertension diagnosis and previous BP control status 2
- Document medication adherence and any side effects from current medications
- Note emergency symptoms if present (headache, visual disturbances, chest pain, dyspnea, neurological symptoms, abdominal pain, nausea, anorexia) 1
Past Medical History
- Document comorbidities that affect hypertension management:
- Cardiovascular disease history (MI, stroke, heart failure) 1
- Diabetes mellitus
- Chronic kidney disease
- Sleep apnea
- Secondary causes of hypertension
Medication History
- Current antihypertensive medications with dosages and timing
- Other medications that may affect BP (NSAIDs, steroids, sympathomimetics) 1
- Document time of most recent BP medication taken before measurements 1
Social History
- Alcohol consumption (document exact amounts)
- Tobacco use status
- Dietary habits, especially sodium intake
- Physical activity level
- Psychosocial stressors 1
Physical Examination
Blood Pressure Measurement (using standardized technique)
- Record BP in both arms at first visit (use arm with higher reading for subsequent measurements) 1
- Document average of ≥2 readings obtained on ≥2 occasions 1
- Note position (seated, after 5 minutes of rest)
- Record cuff size used 1
Other Vital Signs
- Heart rate
- Respiratory rate
- Temperature
- Weight, height, and BMI 2
Cardiovascular Examination
- Heart sounds and rhythm
- Presence of murmurs or gallops
- Peripheral pulses
- Evidence of heart failure (jugular venous distension, pulmonary edema) 1
Other Relevant Systems
- Fundoscopic examination findings 1
- Neurological examination if symptoms present
- Abdominal examination (renal bruits, masses)
Assessment
Hypertension Classification
- Stage 1: SBP 130-139 mmHg or DBP 80-89 mmHg
- Stage 2: SBP ≥140 mmHg or DBP ≥90 mmHg 2
- Hypertensive urgency/emergency if applicable 3
Cardiovascular Risk Assessment
- 10-year ASCVD risk score calculation 1, 2
- Target organ damage assessment:
- Heart (LVH, heart failure, coronary disease)
- Brain (stroke, TIA)
- Chronic kidney disease
- Peripheral arterial disease
- Retinopathy 1
Laboratory and Diagnostic Results
- Basic laboratory tests:
- Urinalysis for blood and protein
- Blood electrolytes and creatinine
- Blood glucose
- Serum total:HDL cholesterol ratio
- 12-lead ECG 1
- Additional tests if indicated:
- Echocardiography
- Renal ultrasound
- Specific tests for secondary hypertension 1
Plan
Blood Pressure Target
- Document individualized BP target (typically <130/80 mmHg for most adults) 2, 4
- Note any modifications based on age, comorbidities, or frailty
Non-Pharmacological Interventions
- DASH diet recommendations
- Sodium restriction (<2 g/day)
- Physical activity prescription (150 minutes/week of moderate-intensity activity)
- Weight management goals
- Alcohol limitation (≤2 drinks/day for men, ≤1 drink/day for women)
- Smoking cessation if applicable 2, 4
Pharmacological Treatment
- First-line medications:
- Document specific medication name, dose, frequency, and titration plan
- Address medication adherence strategies:
- Simplify regimen to once-daily dosing when possible
- Incorporate treatment into patient's daily routine
- Minimize cost of therapy 1
Patient Education
- Explanation of hypertension as a chronic condition
- Importance of medication adherence
- Recognition of side effects
- When to seek medical attention 2
- Home BP monitoring instructions 1
Follow-up Plan
- Timing of next appointment
- Laboratory monitoring schedule
- Home BP monitoring instructions
- Criteria for contacting healthcare provider between visits 2
Common Pitfalls to Avoid in Hypertension Documentation
- Failing to document proper BP measurement technique
- Not averaging multiple BP readings
- Omitting cardiovascular risk assessment
- Incomplete medication reconciliation
- Lack of specific follow-up instructions
- Missing documentation of patient education
- Inadequate assessment of medication adherence
- Not addressing lifestyle modifications 1
By following this structured approach to patient notes for hypertension, clinicians can ensure comprehensive documentation that facilitates optimal management and communication among healthcare providers.