BFC - KM - SOAP - FU - Episodic

Finished note

Example — generated by Notat from a sample visit

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™

Template

Visit Summary:
[Current date here (day- non-numeric month - year):] Could you please summarize the above into a professional yet concise one-paragraph summary, starting with the date, no more than four lines, for their primary care provider, one for the mother, and one for the infant of the plan today, this is meant to send back to the referring care provider about what progress we have made, what we are still working on, what has stayed the same, and what changes we are making. Please utilize the provider's "summary" that is provided at the end of the interaction to create this note.
_________________________________________________________________________________

[Current date here (day- non-numeric month - year): 
Subjective; (Name of patients here)
1. Parent Nipple/Areola/Breast/Feeding Discomfort: [Detailed history of parent nipple, areola, breast, or feeding discomfort, including onset, duration, severity, associated symptoms, previous treatments, and impact on feeding]
2. Parent Mental Health: [Description of parent’s mental health status, including any worries, concerns, mood, anxiety, stressors, coping strategies, support provided, and plan for follow-up]
3. Parent Lactation: [Details of milk supply, production, letdown, any issues with lactation, previous interventions, and goals]
4. Parent Galactogogue use [Details of use of prescription and herbal medication, common ones we use are Domperidone and Metformin. Note what dose they are taking, if their dosing has changed.
5. Parent Mechanical Milk Removal: [Description of mechanical milk removal methods, frequency, devices used, fit and comfort, any issues, adjustments, and recommendations]
6. Child Growth: [History of child’s growth, weight gain, feeding frequency, any concerns, previous measurements, and parental observations]
7. Child Feeding/Tools: [Details of child’s feeding methods, tools used (bottle, nipple shield, etc.), any difficulties, changes, and parental feedback]
8. Child Behaviour and Symptoms: [Description of child’s behaviour during feeding, symptoms such as fussiness, crying, sleep, and any other relevant observations]
9. Child Myofascial/Headshape/Body Tension: [History of child’s body tension, head shape, neck movement, any therapy received, and parental concerns
10. Child Oral Motor/Tongue: [Detailed note regarding oral motor function, tongue movement, feeding challenges, and if frenectomy or follow-up is discussed, include questions, concerns, wound care description, follow-up interval, red flag symptoms, feelings, improvements, unchanged or worsened feeding, wound care completion, need to stop or continue, changes or struggles since last visit, step-wise plan, and goals of parent and provider]
11. Other Concerns/Notes: [Any other medical concerns discussed for parent or child, with detailed history, answers to provider questions, and robust subjective information. If multiple concerns, list as bullet points.]
_________________________________________________________________________________
Assessment and Plan:  [Do not write assessment and plan, please ensure assessment follows right after heading, and then plan follows after, make these all on the same line, no bullet points, please make as detailed as possible and do not add or make up any information that was not provided to you]
[Current date here (day- non-numeric month - year):]

-(If a the parent has additional concerns, or relevant ongoing medical history such as a chronic disease, or ongoing medication use, or non related lactation or feeding cocnern please create sections for these concerns individually here and label it appropria. The formatting should following the below sections with insert today's date before starting this section. Please use the format “day-month-year. Following the date, include all relevant details they have provided. Example: the patient has chronic, well conrolled Chrones Disease.  Please create a section that documents this, state of disease, medications they are on. This will serve to remind the clinician about this concern at every visit. There can be multiple of these if required)

-Parent Nipple/Areola/Breast/Feeding Discomfort: [Current date here (day- non-numeric month - year):][Assessment of discomfort, contributing factors, and plan for management, including specific treatments, medications with dose and duration, and follow-up]
-Parent Mental Health: [Current date here (day- non-numeric month - year):] [Assessment of mental health, support provided, reassurance, and plan for ongoing monitoring and follow-up]
-Parent Lactation: [Current date here (day- non-numeric month - year):] [Assessment of lactation status, contributing factors, and plan for optimizing milk supply, including interventions and follow-up]
-Parent Mechanical Milk Removal: [Current date here (day- non-numeric month - year):][Assessment of mechanical milk removal, device fit, comfort, and plan for adjustments, recommendations, and follow-up]
-Child Growth: [Current date here (day- non-numeric month - year):][Assessment of child’s growth, adequacy of weight gain, and plan for monitoring, interventions, and follow-up]
-Child Feeding/Tools: [Current date here (day- non-numeric month - year):][Assessment of feeding methods and tools, challenges, and plan for modifications, recommendations, and follow-up]
-Child Behaviour and Symptoms: [Current date here (day- non-numeric month - year):] [Assessment of child’s behaviour and symptoms, contributing factors, and plan for management and follow-up]
-(If a the child has additional concerns, or relevant ongoing medical history such as a chronic disease, or ongoing medication use, or non related lactation or feeding cocnern please create sections for these concerns individually here and label it appropria. The formatting should following the below sections with insert today's date before starting this section. Please use the format “day-month-year. Following the date, include all relevant details they have provided. Example: the patient has known or suspected gastroesopahgeal reflux.  Please create a section that documents this, state of disease, medications they are on. This will serve to remind the clinician about this concern at every visit. There can multiple of these if required)
-Child Myofascial/Headshape/Body Tension: [Current date here (day- non-numeric month - year):][Assessment of body tension, head shape, and plan for therapy, interventions, and follow-up]
-Child Oral Motor/Tongue: [Current date here (day- non-numeric month - year):] [Assessment of oral motor function, tongue movement, feeding challenges, and if frenectomy or follow-up, detailed evaluation of procedure, wound care, feeding changes, plan for ongoing care, stepwise plan, and goals]
-Other Concerns/Notes: [Current date here (day- non-numeric month - year):][Assessment and plan for each additional concern, with detailed management steps, recommendations, and follow-up. If multiple concerns, list as bullet points.]