New Patient Visit

Complete intake documentation — chief complaint, history, exam, assessment, and plan captured in one visit.

Use this template in Notat, free

Blank template

Section headings in the order clinicians use them. Paste into your EHR or note tool.

1
Chief Complaint
2
History of Present Illness
3
Past Medical History
4
Medications
5
Allergies
6
Social History
7
Family History
8
Review of Systems
9
Physical Examination
10
Assessment & Plan

Filled example

Patient

42-year-old male, new patient

Chief Complaint

Chest pressure, left-sided, 3 weeks duration.

History of Present Illness

Patient reports dull, substernal chest pressure radiating to the left arm, onset approximately 3 weeks ago. Pressure is intermittent, worse with exertion, lasts 5-10 minutes, relieved by rest. Denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope. No recent illness or fever.

Past Medical History

Hypertension, diagnosed 8 years ago. Hyperlipidemia. No prior cardiac workup.

Medications

Lisinopril 10 mg daily (reports inconsistent adherence). Atorvastatin 20 mg at bedtime (recently started).

Allergies

NKDA

Social History

Occasional ethanol use (2-3 drinks/week). Never smoker. Works as software engineer, sedentary occupation. Lives with spouse and two children.

Family History

Father: MI at age 52. Mother: HTN, T2DM. Brother: hyperlipidemia.

Review of Systems

Constitutional: denies fever, chills, weight change. Cardiovascular: chest pressure as above, no edema, no claudication. Respiratory: negative. GI: negative. GU: negative. Neuro: negative. Endocrine: denies polyuria, polydipsia.

Physical Examination

General: well-developed, no acute distress. Vitals: BP 148/92, HR 78, RR 16, Temp 98.6 F, SpO2 98% RA. CV: RRR, no murmurs, gallops, or rubs. JVP not elevated. No peripheral edema. Lungs: CTAB bilaterally. Abdomen: soft, NT/ND, no HSM.

Assessment & Plan

1. Chest pain with typical anginal features (substernal, exertional, relieved by rest) — suspected stable coronary artery disease given HTN, hyperlipidemia, and family history of premature MI.

- ECG today: normal sinus rhythm, no ischemic changes

- Start aspirin 81 mg daily; sublingual nitroglycerin 0.4 mg PRN chest pain

- Labs: troponin not indicated (no rest pain); BMP, lipid panel, HbA1c

- Exercise stress test referral

- Go to the ED for chest pain at rest or lasting more than 15 minutes

2. Hypertension, above goal — counsel on adherence to lisinopril; recheck BP at follow-up

- Low-sodium DASH diet; aerobic exercise to begin after stress test

- Return in 1 week for results

Example output — generated by Notat AI from a recorded consultation. This is a demonstration; actual notes vary by patient and encounter.

How Notat fills this in

1

You talk with the patient

Notat listens in the background. No dictation commands, no typing during the visit.

2

Facts come first

The FactsContext™ engine extracts the clinical facts, each linked to what was said, so you can check them.

3

The note is written from those facts

Notat fills in this template from the checked facts. You review, edit, and sign.

What this format captures

This example shows the structure clinicians use to keep the important parts of a consultation clear, complete, and easy to review.

From conversation to completed note

Talk naturally with the patient. Notat identifies the clinical facts, organizes them into the right sections, and writes the note in the format your workflow requires.

Let Notat write detailed notes from your consultations.

Notat extracts the clinical facts first, then writes the note from those facts for you to review and sign.

Use this template in Notat, free