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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
<b>S:</b> (hyphenated list) - [Brief statement of chief complaint or reason for visit] - [Relevant associated history in chronological order] - [Past medical history if relevant] - [Medications if relevant] <b>O:</b> (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Physical exam findings and/or mental status exam findings directly examined] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant) - [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan) <b>A:</b> (hyphenated list) - [Diagnosis and reasoning] (Use medical terminology if appropriate. Only include active issues being managed during the visit, do not list stable chronic conditions, resolved issues, or past medical history) - [Differential diagnosis if mentioned] <b>P:</b> (hyphenated list) - [Investigations planned or ordered] - [Treatment plan] - [Counselling discussion] - [Referrals sent] - [Follow up plan] - [Return precautions] (ensure note is as concise as possible)
Shared by
SL
Dr. Sofie Lindqvist
Clinic Director, Sweden
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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