Plastic Surgery Consult

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™

Template

Plastic Surgery Consult

[Date and time if mentioned]

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

History of Present Illness:
(Structure symptoms, mechanism of injury or concern, and associated information into distinct paragraphs. Use full sentences and formal clinical language.)

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Past Surgical History:
(hyphenated list)
- [Prior surgeries and dates if known]

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., Mother: breast cancer)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Review of Systems:
(hyphenated list)
- [Pertinent positives and negatives relevant to the consult]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Inspection: location, size, shape, color, and characteristics of lesion/wound/deformity]
- [Palpation: tenderness, fluctuance, crepitus, temperature, masses]
- [Neurovascular status: sensation, motor function, capillary refill, pulses]
- [Range of motion if relevant]
- [Other relevant system exams]

Imaging and 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, and primary diagnosis or reason for consult]

#) [Assessment as a numbered item if multiple issues]
(Hyphenated list with each corresponding plan item on a new line)
- [Further investigations or imaging]
- [Medical management]
- [Surgical/procedural recommendations]
- [Wound care instructions]
- [Consults to other services]
- [Patient counselling and education]
- [Follow up plan]
- [Return precautions]