Genetic Counseling Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm.

Assessment:
Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed.

Plan:
Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise.

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

Genetic Counsellor Note

Patient Identification: [Patient name, age, gender, referral reason, relevant history]

Reason for Referral:
[Brief statement of reason for genetic counselling, including indication for referral]

History of Present Illness:
[Summary of presenting concerns, relevant symptoms, and chronology]

Past Medical History:
(hyphenated list)
- [Relevant medical diagnoses]
- [Surgical history]
- [Other pertinent health information]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/other allergies, specify reaction]

Family History:
(hyphenated list)
- [Relative: Age, health status, relevant diagnoses, age at diagnosis, cause of death if applicable]
- [Include at least three generations if possible]
- [Consanguinity if present]
- [Ethnic background if relevant]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Genetic Testing History:
(hyphenated list)
- [Previous genetic tests performed, results, date]
- [Testing in family members, results, date]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant physical exam findings, dysmorphic features, growth parameters]

Investigations:
(hyphenated list)
- [Relevant laboratory, imaging, or genetic test results]

Assessment:
[Summary statement including risk assessment, inheritance pattern, and differential diagnosis if applicable]

Plan:
(hyphenated list)
- [Genetic testing recommended or ordered]
- [Counselling provided: inheritance, risk to relatives, reproductive options, psychosocial support]
- [Referrals to other specialists]
- [Educational resources provided]
- [Follow up plan]
- [Return precautions]