Genetics Consult

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

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

Genetics Consult Note

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

Reason for Referral:
[Specific reason for genetics consult, e.g., abnormal test result, family history, suspected syndrome]

History of Present Illness:
(Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language)

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, including previous genetic diagnoses if applicable]

Surgical History:
(hyphenated list)
- [Procedure, date, indication]

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

Allergies:
(hyphenated list)
- [e.g., No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis, age at diagnosis if known]
- [Include three-generation pedigree information if available]
- [Consanguinity if present]

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]

Developmental History (if pediatric or relevant):
(hyphenated list)
- [Milestones: age achieved]
- [School performance]
- [Behavioral concerns]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Growth parameters: height, weight, head circumference with percentiles if pediatric]
- [Dysmorphic features: description]
- [System: Exam findings, one system per line]

Investigations:
(hyphenated list)
- [Genetic testing results with details]
- [Other relevant laboratory or imaging results]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary genetic concern or diagnosis]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line if mentioned)
- [Further genetic testing planned or recommended]
- [Referrals to other specialties]
- [Genetic counseling provided or planned]
- [Family member testing recommendations]
- [Management or surveillance recommendations]
- [Follow up plan]
- [Return precautions]