Gynaecology Consult Note

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

Gynaecology Consult

Date/Time: [Insert date and time of consult]

Reason for Consult: [Concise statement of why the consult was requested, by whom, and what issue is to be addressed]

Patient Identification: [Patient name, age, gender, GTPAL, brief relevant background]

History of Presenting Complaint: 

(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Obstetric History:
(hyphenated list)
- Gravida: [#]
- Para: [#]
- Term births: [#]
- Preterm births: [#]
- Abortions (spontaneous/induced): [#]
- Living children: [#]
- Obstetric complications: [details]

Menstrual History:
(in paragraphs)
- [Age at menarche; cycle length, regularity, duration; date of last menstrual period; associated symptoms]

Contraceptive History:
(in paragraphs)
- [Type(s) of contraception used, duration, tolerability, reason for discontinuation if applicable]

Gynaecological History:
(hyphenated list)
- Fibroids: [Yes/No; size/location if known]
- Endometriosis: [Yes/No; extent if known]
- Uterine anomalies: [Yes/No; details]
- Prior cervical cytology (Pap) results: [Date and result]
- History of sexually transmitted infections: [Type, treatment]

Sexual History:
(in paragraphs)
- [Number of partners, age at first intercourse, contraception/protection practices, sexual function concerns]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

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

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- General appearance: [description]
- Abdomen: [inspection, palpation findings]
- Pelvic examination:
 - External genitalia: [findings]
 - Speculum exam: [cervix appearance, discharge]
 - Bimanual exam: [uterine size/position, adnexal findings]
- Other systems as indicated: [e.g., cardiovascular, respiratory]

Investigations:
(hyphenated list)
- Laboratory studies: [Test name: result (units)]
- Imaging studies: [Modality (e.g., pelvic ultrasound), key findings]
- Other diagnostics: [e.g., endometrial biopsy]

Assessment & Plan:
(Use medical terminology as appropriate)
[One‐sentence summary including age, sex, GTPAL, and primary gynaecologic issue]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]