Preventive Medicine Visit Note

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

Preventative Medicine Note

Patient Identification:
[Patient name, age, gender]

Reason for Visit:
[Reason for preventative visit, e.g., annual physical, health maintenance, screening]

History of Present Illness:
[Brief summary of current health status, any new symptoms, concerns, or changes since last visit]

Past Medical History:
(hyphenated list)
- [Chronic conditions]
- [Previous surgeries]
- [Hospitalizations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, environmental allergies]
- [No known drug allergies (NKDA) if applicable]

Family History:
(hyphenated list)
- [Relevant family conditions, e.g., cardiovascular disease, cancer, diabetes]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration, quit date if applicable]
- [Alcohol use: type, amount, frequency]
- [Recreational drug use: type, amount, frequency]
- [Occupation and exposures]
- [Living situation and support system]
- [Physical activity level]
- [Dietary habits]

Immunization Status:
(hyphenated list)
- [Vaccines received and dates]
- [Vaccines due or recommended]

Screening History:
(hyphenated list)
- [Cancer screenings: colonoscopy, mammogram, Pap smear, PSA, etc.]
- [Cardiovascular screenings: lipid panel, blood pressure, etc.]
- [Other relevant screenings: bone density, diabetes, STIs, etc.]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings by system] (Format as "System: Exam findings", one system per line)

Investigations:
(hyphenated list)
- [Recent or pending laboratory and imaging results]

Assessment:
(hyphenated list)
- [Summary of health status]
- [Risk factors identified]
- [Preventative care needs]

Plan:
(hyphenated list)
- [Recommended screenings and follow-up]
- [Immunizations to be administered or scheduled]
- [Lifestyle counselling: diet, exercise, substance use]
- [Referrals to specialists if needed]
- [Patient education provided]
- [Follow-up interval]
- [Return precautions]