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Obesity Specialist

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Obesity Management Note

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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

Obesity Note Template

Subjective:
(hyphenated list)
- [Chief complaint or reason for visit]
- [Duration and progression of weight gain]
- [Associated symptoms: fatigue, shortness of breath, joint pain, sleep disturbances, mood changes]
- [Dietary habits: typical daily intake, snacking, meal patterns]
- [Physical activity level: type, frequency, duration]
- [Previous weight loss attempts: methods, outcomes]
- [Impact on daily life and functioning]
- [Motivation and readiness for change]

Objective:
(hyphenated list)
- [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Height, weight, BMI calculation]
- [Physical exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)
- [Relevant findings: acanthosis nigricans, joint tenderness, edema, signs of secondary causes]

Assessment:
(hyphenated list)
- [Obesity diagnosis: specify class if applicable (e.g., Class I, II, III)]
- [Contributing factors: lifestyle, medical, psychosocial]
- [Complications: hypertension, diabetes, dyslipidemia, sleep apnea, osteoarthritis, depression]
- [Differential diagnosis if secondary causes suspected]

Plan:
(hyphenated list)
- [Laboratory investigations: fasting glucose, HbA1c, lipid panel, liver function tests, TSH, others as indicated]
- [Lifestyle modification: dietary counseling, physical activity recommendations]
- [Behavioral interventions: referral to dietitian, psychologist, support groups]
- [Pharmacotherapy: if indicated, specify medication, dose, monitoring]
- [Consideration for bariatric surgery: criteria, referral if appropriate]
- [Monitoring: follow-up interval, weight tracking, reassessment of comorbidities]
- [Patient education: risks, benefits, realistic goals]
- [Return precautions: symptoms warranting urgent evaluation]

Shared by

AB

Dr. Amalie Berg

General Practitioner, Norway

How it works in Notat

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