1,009 uses
Prenatal Consult (Shah)
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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Follow-up for heavy menstrual bleeding over several cycles, with fatigue. No severe pelvic pain or pregnancy concern reported. Assessment: Abnormal uterine bleeding requiring routine investigation. Plan: Discussed symptom diary, relevant blood tests, and follow-up after results. Urgent review advised for severe pain, dizziness, or very heavy bleeding. 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
Bleeding: Heavy menstrual bleeding over several cycles
Associated symptom: Fatigue
denials of symptoms
Denies: Red flags: No severe pelvic pain or pregnancy concern reported
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Investigation: Symptom diary and blood tests discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
[Patient identification and reason for referral] [Patient name] is a [age]-year-old [gravida and parity in G#P# format] at [gestational age] weeks, referred for [reason for referral]. [History of current pregnancy in paragraph form].The patient presents with a pregnancy that has been [spontaneous/IVF], currently at [gestational age] weeks. diabetes or hypertension in this pregnancy. Serologies are protective, with rubella immunity confirmed. Blood type is [blood type]. First trimester screening was [low risk/high risk/not performed]. Group B Streptococcus screening is [negative/positive/not tested]. There is no history of gestational Anatomy ultrasound was normal, with the placenta clear of the os. The most recent ultrasound, performed on [date], showed [findings]. [Obstetrical history, details of previous pregnancies, deliveries, complications, and outcomes] Gynecological history includes [last menstrual period], with cycles typically lasting [cycle length] days and menstruation duration of [duration] days. The patient reports [intermenstrual bleeding/dysmenorrhea/postcoital bleeding/vaginal discharge] as [present/absent].The last pap exam was performed in [year], with [results]. Previous pap tests have been [normal/abnormal], with [details if abnormal]. [Past medical history] [Past surgical history] [Current medications] [Allergies] [Social history] [Vitals and physical examination] In summary, this is a [age]-year-old [gravida and parity] at [gestational age] weeks, referred for [reason for referral]. The plan is to [plan details], with follow up arranged for [timeline]. The patient was advised regarding return precautions, including [return precautions]. [Other plan items].
Shared by
PN
Dr. Priya Nair
Pediatrician, Singapore
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