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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
Rheumatology Consultation Template Patient Identification: [Patient name, age, gender, with a history of..., presenting with...] History of Present Illness: [Detailed description of presenting symptoms, including onset, duration, progression, pattern, and associated features such as pain, swelling, stiffness, fatigue, rash, fever, or other systemic symptoms] [Relevant prior treatments, response to therapy, and impact on function or quality of life] Past Medical History: (hyphenated list) - [Relevant chronic illnesses, prior rheumatologic diagnoses, surgeries, hospitalizations] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Include disease-modifying antirheumatic drugs (DMARDs), biologics, NSAIDs, corticosteroids, supplements] Allergies: (hyphenated list) - [Drug allergies and reactions] - [Other allergies] Family History: (hyphenated list) - [Autoimmune or rheumatologic conditions in first-degree relatives] - [Other relevant family history] 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] - [Functional status: ability to perform activities of daily living, work, exercise] Review of Systems: (hyphenated list) - [General: fever, weight loss, fatigue] - [Musculoskeletal: joint pain, swelling, stiffness, weakness] - [Skin: rash, nodules, ulcers] - [Eyes: redness, pain, vision changes] - [Cardiopulmonary: chest pain, dyspnea, cough] - [GI: abdominal pain, diarrhea, oral ulcers] - [GU: dysuria, hematuria] - [Neurologic: headache, numbness, weakness] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Musculoskeletal: joint inspection, swelling, tenderness, range of motion, deformities, muscle strength] - [Skin: rashes, nodules, ulcers] - [Eyes: conjunctivitis, scleritis, uveitis] - [Other systems as relevant] Investigations: (hyphenated list) - [Laboratory results: CBC, ESR, CRP, RF, anti-CCP, ANA, ENA panel, uric acid, HLA typing, etc.] - [Imaging: X-rays, ultrasound, MRI, CT] - [Other relevant tests] Assessment & Plan: [One-sentence patient summary including age, sex, and primary rheumatologic diagnosis or concern] #) [Assessment as a numbered item for each active issue] (hyphenated list with each corresponding plan item on a new line) - [Investigations planned or ordered] - [Treatment plan: medication changes, initiation, discontinuation] - [Non-pharmacologic management: physical therapy, occupational therapy, lifestyle modifications] - [Counselling discussion: disease education, medication risks/benefits, prognosis] - [Referrals sent: other specialties, allied health] - [Follow up plan: timing, location, specific goals] - [Return precautions] Thank you for allowing me to participate in this patient care Dictated using voice recognition software and therefore may contain typographical errors
Shared by
MB
Dr. Marc Beaulieu
Family Physician, Canada
How it works in Notat
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