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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™
symptoms
Bleeding: Heavy menstrual bleeding over several cycles
Associated symptom: Fatigue
denials of symptoms
Denies: Red flags: No severe pelvic pain or pregnancy concern reported
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Investigation: Symptom diary and blood tests discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
(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]
Shared by
AK
Dr. Anna Kowalska
Gynecologist, Poland
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