Malli struktuur
See on struktuur, mida Notat järgib visiidi põhjal märkme kirjutamisel — sa ei täida seda kunagi käsitsi.
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
S: Here today for diabetes visit. No changes in medication since last seen. Over all feels doing well. Patient currently taking (add diabetic medication) O/E BP: Please see diabetes flow sheet below A1C: [current A1C] increased/decreased from [previous A1C] LDL: [current LDL] increased/decreased from [previous LDL] HDL: [current HDL] increased/decreased from [ previous HDL] Wt: [current wt in kilograms ] increased/decreased from [previous wt in kilograms ] A: Diabetes under good/sub optimal control LDL at target/not at target Weight up/down from last apt BP is at/not at target Discussed insulin regime in detail P: Advised to continue with diabetic diet/exercise etc I have advised to continue with current medication regime I have added the following medications to current regime: I will see back in 3/6 months for diabetic visit See sooner with any other concerns
Jagas
DV
Dr. Daniel Visser
Geriatrician, Netherlands
Kuidas see Notatis töötab
Lisa see mall oma malliteeki, salvesta visiit nagu tavaliselt ja Notat koostab märkme täpselt selles struktuuris, kasutades visiidist eraldatud kliinilisi fakte. Sina vaatad üle, muudad ja allkirjastad.
Proovi Notatit — see on tasuta