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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™
symptoms
Presenting concern: Persistent cough and reduced energy for 10 days
history of present illness
Progress: Symptoms are gradually improving
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
physical exam
Red flags: No red flags identified in today’s review
plan
Follow-up: Safety-netting and review if symptoms persist or worsen
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
denials of symptoms
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
Template
HPIHistory of Present Illness: (Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language) Review of systemsReview of Systems: (Document pertinent positives and negatives as reported by patient) Allergic/Immunologic: [Allergy/Immunology ROS] (Seasonal allergies, hives, frequent infections) Cardiovascular: [Cardiovascular ROS] (Chest pain, palpitations, dyspnea on exertion, orthopnea, edema) Constitutional: [Constitutional ROS] (Fever, chills, weight change, fatigue) ENT: [ENT ROS] (Ear pain, hearing changes, tinnitus, sore throat, congestion, epistaxis) Endocrine: [Endocrine ROS] (Heat/cold intolerance, excessive thirst/urination, changes in hair/skin) Eyes: [Eyes ROS] (Vision changes, pain, redness, discharge) Gastrointestinal: [GI ROS] (Nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, melena, hematochezia) Genitourinary: [GU ROS] (Dysuria, frequency, urgency, hematuria, incontinence, hesitancy, nocturia,) [Gender Specific GU ROS] (Vaginal discharge/bleeding, penile discharge, testicular pain,) Hematologic/Lymphatic: [Heme/Lymph ROS] (Easy bruising, bleeding, swollen glands) integumentary: [Skin ROS] (Rashes, lesions, itching, dryness, changes in moles) Musculoskeletal: [MSK ROS] (Joint pain, stiffness, swelling, redness, muscle pain, weakness, back pain) Neurological: [Neuro ROS] (Headache, dizziness, syncope, numbness, tingling, weakness, seizures, memory changes?) Psychiatric: [Psychiatric ROS] (Anxiety, depression, mood changes, sleep disturbance, suicidal ideation, homicidal ideation) Respiratory: [Respiratory ROS] (Cough, sputum, shortness of breath, wheezing, hemoptysis) Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant) Assessment & Plan: (Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate.) [One-sentence patient summary including age, sex, and primary diagnosis] #) [Assessment as a numbered item if mentioned] - [Hyphenated list with each corresponding plan item on a new line if mentioned] ICD-10 Code: [Enter the most clinically relevant ICD-10 code for this encounter]
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Dr. Aino Laine
General Practitioner, Finland
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