4,007 bruger
Obstetrics Triage Note
Se notatet, før du bruger skabelonen
Start med et færdigt eksempel, gennemgå skabelonen, eller se de kliniske fakta, Notat bruger til at udarbejde notatet.
Færdigt notat
Eksempel — genereret af Notat ud fra et eksempelbesøg
Presenting concern: Follow-up for heavy menstrual bleeding over several cycles, with fatigue. No severe pelvic pain or pregnancy concern reported. Assessment: Abnormal uterine bleeding requiring routine investigation. Plan: Discussed symptom diary, relevant blood tests, and follow-up after results. Urgent review advised for severe pain, dizziness, or very heavy bleeding. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Bleeding: Heavy menstrual bleeding over several cycles
Associated symptom: Fatigue
denials of symptoms
Denies: Red flags: No severe pelvic pain or pregnancy concern reported
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Investigation: Symptom diary and blood tests discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Skabelon
ID: [Patient name] is a [Age] [Gravida/Para status] at [Gestational age] Chief Complaint: [Chief complaint] History of present illness - [History of present illness] - [Contractions] - [Leakage of fluids] - [Vaginal bleeding] Current pregnancy: (hyphenated list) - [Pregnancy conception method: Spontaneous/IVF] - Gestational diabetes: [Yes/No] - Hypertension: [Yes/No] - Serologies [protective/non-protective] - Rubella: [Immune/Non-immune] - Hepatitis B: [non-reactive/reactive] - Hepatitis C: [non-reactive/reactive] - HIV: [non-reactive/reactive] - Syphillis: [non-reactive/reactive] - G/C: [negative/positive] - GBS: [negative/positive] - Blood type: [Blood type], Rh: [positive/negative] - FTS: [Low risk/Other] - Anatomy U/S: [Normal/Abnormal, placenta location] - Last U/S: [Date and findings] Ob Hx: (hyphenated list) - [Obstetrical history details: previous pregnancies, outcomes, complications] PMHx: [Past medical history] SHx: [Social history] Meds: [Current medications] Allergies: [Allergies] O/E: (hyphenated list) - [Vital signs] - Abdomen: [Findings] - Vaginal: [Findings] - Speculum: [Findings] - FHR: [Fetal heart rate] - Toco: [Tocometry findings] A/P: [Age] [Gravida/Para status] at [Gestational age] presenting with [...]. [Primary diagnosis], - [Investigations planned or ordered] - [Treatment plan] - [Counselling discussion] - [Referrals sent] - [Follow up plan] - [Return precautions]
Delt af
PN
Dr. Priya Nair
Pediatrician, Singapore
Sådan fungerer det i Notat
Tilføj denne skabelon til dit bibliotek, optag besøget som sædvanligt, og Notat udarbejder notatet i denne præcise struktur ud fra de udtrukne kliniske fakta. Du gennemgår, redigerer og underskriver.
Prøv Notat — det er gratis