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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
Summary of Visit: (Briefly explain the diagnosis in simple, patient-friendly language, and explain what it is to the patient. Do not list subjective or objective information unless relevant. Use full sentences only.) Treatment: (only include this header if treatment mentioned) (hyphenated list, only include new medications started today, do not include reference to medications the patient is already on. Include other treatments that are not medications, e.g. nasal saline, rest, hydration, etc.) - [Medication name, dose, route, frequency if mentioned] - [e.g., Metformin 500 mg by mouth twice daily] Follow-Up Instructions: (include this header if instructions mentioned) (hyphenated list) - [Bloodwork requested] (include blood work lab location, hours, how to book if mentioned) - [Imaging requested] (include imaging facility location, hours, how to book if mentioned) (if CT or MRI booked, make reference that patient will receive a call to book this and wait time is variable depending on urgency] - [Specialist appointment date and time] (if referral made to specialist, make reference that patient will recieve a call to book this and wait time is variable depending on urgency) - [Follow up appointment date and time] Go to the nearest emergency department if: (hyphenated list) - [life threatening conditions relevant to their diagnosis] If you have any questions or concerns, contact our clinic or seek urgent care. It was a pleasure being involved in your care. (do not include medical abbreviations in this note, e.g. SOB, CP, BID)
Shared by
AL
Dr. Aino Laine
General Practitioner, Finland
How it works in Notat
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