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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
Toxicologist Note Patient Identification: [Patient name, age, gender, with a history of..., presenting with...] History of Present Illness: [Detailed description of exposure or ingestion, including substance, amount, route, timing, circumstances] [Associated symptoms and progression] [Interventions prior to arrival, if any] Past Medical History: (hyphenated list) - [Relevant medical conditions] - [Psychiatric history] - [Previous toxic exposures] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Recent changes or overdoses] Allergies: (hyphenated list) - [Drug, food, environmental allergies] - [Reaction type] Family History: (hyphenated list) - [Relevant familial conditions] - [History of substance abuse or psychiatric illness] 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] Exposure Details: (hyphenated list) - [Substance(s) involved] - [Amount and concentration] - [Route of exposure] - [Time of exposure] - [Intent (accidental, intentional, unknown)] - [Source of substance] - [Co-exposures] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Mental status] - [Skin findings] - [Pupils] - [Cardiovascular] - [Respiratory] - [Gastrointestinal] - [Neurological] - [Other relevant systems] Investigations: (hyphenated list) - [Laboratory results with units] (e.g., CBC, electrolytes, liver function, toxicology screen) - [Imaging results] - [ECG findings] - [Other relevant tests] Assessment & Plan: [One-sentence patient summary including age, sex, substance(s) involved, and clinical status] #) [Assessment as a numbered item if multiple issues] (hyphenated list with each corresponding plan item on a new line) - [Diagnosis and reasoning] - [Risk assessment and prognosis] - [Decontamination measures] - [Antidote administration] - [Supportive care] - [Monitoring plan] - [Consultations requested] - [Counselling and education] - [Follow up plan] - [Return precautions]
Shared by
CM
Dr. Claire Murphy
General Practitioner, Australia
How it works in Notat
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