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Urogynecology Consultation Note
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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Follow-up for heavy menstrual bleeding over several cycles, with fatigue. No severe pelvic pain or pregnancy concern reported. Assessment: Abnormal uterine bleeding requiring routine investigation. Plan: Discussed symptom diary, relevant blood tests, and follow-up after results. Urgent review advised for severe pain, dizziness, or very heavy bleeding. 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
Bleeding: Heavy menstrual bleeding over several cycles
Associated symptom: Fatigue
denials of symptoms
Denies: Red flags: No severe pelvic pain or pregnancy concern reported
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Investigation: Symptom diary and blood tests discussed
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
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]
Shared by
PN
Dr. Priya Nair
Pediatrician, Singapore
How it works in Notat
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