Urogynecology Consultation Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Urogynecology Consultation Note

Patient Identification: [Patient name, age, gender, relevant history, presenting complaint]

History of Present Illness:
[Detailed description of presenting symptoms, including onset, duration, severity, aggravating/relieving factors, associated urinary, pelvic, or bowel symptoms]
[Relevant gynecologic, obstetric, and surgical history]
[Impact of symptoms on quality of life and daily activities]

Past Medical History:
(hyphenated list)
- [Medical conditions]

Past Surgical History:
(hyphenated list)
- [Surgical procedures, dates]

Obstetric History:
(hyphenated list)
- [Gravida, para, mode of deliveries, complications]

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

Allergies:
(hyphenated list)
- [Drug/other allergies and reactions]

Family History:
(hyphenated list)
- [Relevant familial conditions]

Social History:
(hyphenated list)
- [Tobacco use]
- [Alcohol use]
- [Recreational drug use]
- [Occupation]
- [Living situation]

Review of Systems:
(hyphenated list)
- [Genitourinary: urgency, frequency, incontinence, retention, dysuria, hematuria]
- [Gynecologic: vaginal discharge, bleeding, pelvic pain, prolapse symptoms]
- [Gastrointestinal: constipation, fecal incontinence]
- [Other relevant systems]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Abdominal exam: findings]
- [Pelvic exam: external genitalia, vaginal mucosa, pelvic organ prolapse (POP-Q if applicable), urethra, pelvic floor muscle strength, tenderness]
- [Neurologic exam: perineal sensation, reflexes]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Urinalysis]
- [Post-void residual]
- [Urodynamics]
- [Imaging results]
- [Other relevant tests]

Assessment & Plan:
[One-sentence summary including age, sex, and primary urogynecologic diagnosis]

#) [Diagnosis or problem as numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered]
- [Medical management]
- [Surgical management]
- [Pelvic floor physical therapy]
- [Lifestyle modifications]
- [Patient education and counselling]
- [Referrals]
- [Follow up plan]
- [Return precautions]