Gyne Consult (Shah)

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

(output full note as distinct paragraphs with narrative style and no headings)

[Patient identification and reason for referral]

[History of present illness in paragraph form. Make it chronological history, make sure it flows properly, so that when someone reads it, they easily understand]

[Gyneacology history including last menstrual period, cycle and duration. Include mention of intermenstrual bleeding, dysmenorrhea, postcoital bleeding, vaginal discharge. Mention if using any contraception. Mention last pap exam and if any history of previous pap tests and results] [Obstetrical history including gravida and pravity in G#P# format]

[Mention past medical history and year of diagnosis] (exclude if not mentioned)

[Mention past surgical history] (exclude if not mentioned)

[Mention medications, dose, frequency, duration and effectiveness] (exclude if not mentioned)

[Allergies] (exclude if not mentioned)

[Substance use history] (exclude if not mentioned)

[Investigations and ultrasound if mentioned, include date if specified]

[Assessment, differential and plan. Include follow up if mentioned. Also include return precautions]