01 / ADAPTABLE OUTLINE
What to document
History & home readings
Review the home log, cuff technique, missed doses, adverse effects, OTC medicines, alcohol, diet, activity, and symptoms suggesting acute organ injury.
Focused examination
Record repeat BP using correct technique, pulse, relevant cardiovascular and pulmonary findings, edema, and neurologic findings when indicated.
Assessment & testing
Document control relative to an individualized goal, contributing factors, renal function and potassium review, and rationale for any additional testing.
Treatment & monitoring
Specify medicine, formulation, dose, route, frequency, changes, adverse-effect counseling, home monitoring, laboratory follow-up, and return interval.
02 / WORKED EXAMPLE
Controlled hypertension on a verified regimen
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
HPI & ROS
A 60-year-old woman returns for established hypertension. She takes lisinopril 10 mg orally daily without cough or dizziness. Home readings are generally 124–134/74–82 mmHg. No chest pain, shortness of breath, or new neurologic symptoms.
Objective
BP 128/78 mmHg on repeat measurement; pulse 72 and regular. Lungs are clear, heart rhythm is regular, and no peripheral edema is present. Recent creatinine and potassium results were reviewed and are within the laboratory reference ranges.
Assessment & plan
Hypertension is at the agreed goal. Continue lisinopril 10 mg orally once daily. Medication reconciliation completed. Discussed sodium reduction, physical activity, and home BP technique. Follow up in three months with the BP log; check renal function and potassium sooner if treatment changes or clinical circumstances warrant. Seek emergency care for chest pain, severe dyspnea, or new focal neurologic symptoms.
A common documentation question
Should every hypertension visit lead to a medication change?
No. Record the trend, adherence, tolerability, and agreed goal. Continuing a verified effective regimen is a specific treatment decision; explain it and document monitoring.
03 / CLINICAL REASONING
Differential & testing considerations
Examples to consider—not diagnoses to automatically include in a note.
Differential
- Established primary hypertension
- Medication or substance contribution
- Secondary hypertension when history, examination, or resistant readings suggest it
Testing & assessment
- Repeat standardized BP and review home measurements.
- Review creatinine/eGFR and potassium before and after relevant medication changes; individualize timing.
- Target additional evaluation to symptoms, comorbidities, and suspected secondary causes.
04 / TREATMENT & DOSAGE REFERENCES
Make the plan specific.
Selected adult references, not a complete protocol or individualized prescription. Check the indication, formulation, allergies, pregnancy, renal/hepatic function, interactions, and current local guidance. Sources checked September 10, 2026.
Lisinopril — adult hypertension reference
Typical initial dose: 10 mg orally once daily; usual range 20–40 mg daily, adjusted to response.
This is a label reference, not a reason to increase a controlled patient's dose. A lower starting dose may be needed with diuretic therapy or renal impairment.
Safety review: Do not use in pregnancy. Review angioedema history, interacting medicines, renal function, potassium, and hypotension risk. Monitor renal function and potassium.
DailyMed: lisinopril prescribing information ↗