Prenatal Consult (Shah)

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

[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].