Occupational Medicine Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

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

Occupational Medicine Consult

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, occupation, with a history of..., presenting with...]

History of Present Illness:
(Structure symptoms, work-related exposures, and associated information into distinct paragraphs. Use full sentences and formal clinical language.)

Occupational History:
(hyphenated list)
- [Current job title and description]
- [Duration of employment]
- [Workplace exposures (chemical, physical, biological, ergonomic)]
- [Use of personal protective equipment]
- [Previous occupational injuries or illnesses]
- [Workplace accommodations or restrictions]

Past Medical History:
(hyphenated list)

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

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: hypertension)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Living situation: who lives with patient, home environment]
- [Hobbies or activities relevant to exposure risk]

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)

Investigations:
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, occupation, and primary diagnosis or concern]

#) [Assessment as a numbered item if mentioned]
(hyphenated list with each corresponding plan item on a new line if mentioned)
- [Workplace modifications or restrictions]
- [Investigations planned or ordered]
- [Treatment plan]
- [Counselling discussion (including return-to-work, workplace safety, prevention)]
- [Referrals sent (e.g., physiotherapy, specialist)]
- [Follow up plan]
- [Return precautions]