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Finished note
Example — generated by Notat from a sample visit
Reason for consultation: Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope. Assessment: Stable clinical presentation requiring further outpatient evaluation. Plan: Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest. 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
Breathlessness: Progressive exertional breathlessness over two months
denials of symptoms
Denies: Associated symptoms: No chest pain at rest or syncope
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
medications
Current treatment: Continue established medicines pending review
plan
Investigations: Outpatient investigations arranged
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
Subjective: (use bullet points) - [Reason(s) for consultation, including specific rheumatologic concerns or symptoms such as joint pain, stiffness, swelling, systemic symptoms like fatigue, fever, weight loss, skin rashes, dry eyes or mouth, etc. (mention if available)] - [Detailed history of the presenting complaint(s), including onset, duration, severity, pattern of joint involvement (symmetrical/asymmetrical), morning stiffness, aggravating/alleviating factors, associated systemic symptoms, any previous treatments (e.g., NSAIDs, DMARDs, biologics) and responses, etc. (mention if available)] - [Past medical and surgical history, highlighting any previous rheumatologic diagnoses, treatments, surgeries, hospitalizations, outcomes, etc. (mention if available)] - [Current medications, including any disease-modifying antirheumatic drugs (DMARDs), biologic agents, pain management medications, supplements, etc. (mention if available)] - [Social history, focusing on lifestyle factors, occupation, smoking, alcohol use, family history of rheumatic diseases, etc. (mention if available)] - [Allergies, including allergies to medications, particularly NSAIDs or biologics, etc. (mention if available)] Objective: - [Vitals (mention if available)] - [Physical examination findings, with emphasis on musculoskeletal examination including joint inspection, palpation, assessment of range of motion, identification of synovitis, bursitis, tenosynovitis, etc, (mention if available)] - [Skin examination for rheumatologic markers, nail changes, etc. (mention only if applicable and if available)] - [Investigations with results, including laboratory tests (use medical abbreviations), imaging studies, etc, (mention if available and group results "WNL" together with commas)] Assessment & Plan: [1. Rheumatologic Issue or Condition] (with ICD-10 Code) - [Assessment, including the likely diagnosis and rationale based on subjective and objective findings (mention if available)] - [Differential diagnosis] - [Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning (mention if available)] - [Medical treatment planned, including details, for e.g., the type of DMARDs, biologics, pain management strategies, dosage, expected outcomes, potential side effects, etc. (mention if applicable and available)] - [Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc (mention only if applicable and available)] - [Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc. (mention if applicable and available)] - [Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans, etc. (mention only if applicable and available)] - [Mention any referrals (mention if applicable and available)] - [Patient education on the diagnosed condition, including explanation of the disease process, potential complications, and the importance of treatment adherence, etc. (mention only if applicable and available)] - [Instructions for symptom monitoring, including joint swelling, pain levels, and any new symptoms indicating disease progression or adverse effects of treatment (mention only if applicable and if available)] - [Any specific patient or family concerns addressed during the consultation (mention only if applicable and if available)] [2. Additional Rheumatologic Issues or Conditions] - [Follow the same structure as above for each additional issue or condition identified (if applicable and if available)]
Shared by
LC
Dr. Laura Conti
Dermatologist, Italy
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
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