How to run and chart a lithium monitoring visit
Lithium follow-up is the trough, the renal and thyroid trend, side effects, interacting meds, and a dose decision that cites those numbers.
A lithium monitoring visit has to show a timed trough, the current dose, renal and thyroid (and usually calcium) labs with trend, the side-effect exam, interacting medicines, and a dose decision that uses those data. If the level is 0.9 and creatinine is climbing, “continue current dose” needs a reason.
Use the lithium monitoring follow-up fields so the numbers do not drown in HPI prose. A 2026 expert opinion on lithium and the kidney, in the International Journal of Bipolar Disorders, is a useful reminder to look at eGFR trajectory instead of a single creatinine.
Confirm it was a trough and write the level
Date drawn, time drawn, hours after last dose, formulation (IR vs ER), total daily dose, and the result in mEq/L (or mmol/L; same number). “Lithium 0.7” without timing is not a trough.
Target range belongs next to the number and the phase of illness. Maintenance often sits around 0.6 to 0.8; older adults often lower; acute mania higher if you are still titrating. Cite the range you are using for this patient.
List the last three or four levels. The decision is the trend. A single in-range value after a missed-dose week is not reassurance.
If the draw was mid-dose or the patient took a morning tablet before the lab, say so and do not treat the number as a trough.
Review renal, thyroid, and calcium
Creatinine, eGFR, TSH, and calcium (PTH if calcium is off). Weight and BP at the visit.
Write the trend, not only today’s values. “eGFR 72, was 88 two years ago, 78 last year” is a monitoring note. “BMP wnl” is not.
The 2026 renal expert opinion many lithium clinicians are reading this spring treats eGFR under 60 as a nephrology-referral conversation, and it warns against reflexively stopping lithium the same day the eGFR crosses a line. Chart the shared decision: suicide risk and relapse risk vs kidney risk, who you messaged in nephrology, and whether you are lowering the mean level rather than stopping.
After intoxication, vomiting, a new ACE inhibitor, ARB, thiazide, or NSAID, or a rapid eGFR drop, tighten the interval and write why.
Chart symptoms, tremor, and interacting meds
Mood interval in bipolar terms (euthymic, depressed, hypo/manic, mixed), sleep, and function.
Side effects that lithium actually produces: fine vs coarse tremor, polyuria and nocturia, thirst, weight, GI, cognitive slowing, acne or psoriasis, hypothyroid symptoms.
Ask the interaction questions out loud and document the answers: ibuprofen, naproxen, new blood-pressure meds, low-sodium diet, dehydration, fever, heavy sweating. These are how people get to 1.4 without a dose change.
Pregnancy status if applicable. Toxicity screen: nausea, coarse tremor, ataxia, confusion. If any of those are present, the visit is no longer a routine monitoring note.
Write the dose decision against the data
Assessment should be readable by covering call.
Bipolar I, currently euthymic 11 months. Lithium ER 900 mg QHS, trough 0.72 (12.5 h post-dose), last four levels 0.68-0.80. eGFR 74 (was 79 last year). TSH 2.1. Fine tremor, no functional impact. No NSAIDs. Decision: continue 900 mg. Not stopping, not reducing; renal slope is mild and mood stability is the current priority. PCP copied on labs.
If you change the dose, name the target level and the next draw date. If you hold for toxicity, write the hold, the next level, and the crisis plan for mood.
Education belongs in the plan: hydration, NSAID warning, sick-day rules, when to call. Coordination with PCP for kidney and thyroid is part of the visit, not an afterthought.
This is the same “decision with a reason” pattern as a complex med-management visit, with labs as the spine.
Sample visit block
Lithium ER 900 mg QHS. Years on lithium: 6.
Trough 0.72 mEq/L, drawn 07:40, last dose 19:00 prior night.
Trend: 0.70, 0.68, 0.80, 0.72.
Cr 1.01, eGFR 74 (79 in 2025). TSH 2.1. Ca 9.4. Weight 84 kg. BP 128/78.
Tremor: fine, postural, no writing change. Nocturia x1. No NSAIDs.
MSE: euthymic, linear, no SI.
Plan: continue 900 mg. Repeat lithium + BMP in 3 months, TSH in 6 months.
Sick-day handout reviewed. Message to PCP with eGFR trend.
Follow-up 3 months, sooner if tremor coarsens or GI illness.