Maternal Fetal Medicine Note

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Esimerkki — Notatin luoma esimerkikäynnistä

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™

Malli

Maternal-Fetal Medicine Note

Patient Identification: [Patient name, age, gravida/para status, gestational age, presenting complaint or reason for referral]

History of Present Illness:
[Detailed description of current pregnancy concerns, symptoms, or reason for MFM consultation. Include relevant obstetric history, timeline of events, and associated symptoms.]

Obstetric History:
(hyphenated list)
- [Gravida, para, abortions, living children]
- [Prior pregnancies: year, outcome, gestational age at delivery, complications]

Gynecologic History:
(hyphenated list)
- [Menstrual history]
- [Contraceptive history]
- [Gynecologic surgeries or conditions]

Past Medical History:
(hyphenated list)
- [Chronic medical conditions]
- [Prior hospitalizations or surgeries]

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

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

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

Family History:
(hyphenated list)
- [Hereditary conditions, pregnancy complications, genetic disorders]

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]

Review of Systems:
(hyphenated list)
- [General: fever, weight change, fatigue]
- [Cardiac: chest pain, palpitations]
- [Respiratory: cough, dyspnea]
- [GI: nausea, vomiting, abdominal pain]
- [GU: dysuria, vaginal bleeding/discharge]
- [Other relevant systems]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Cardiac exam]
- [Respiratory exam]
- [Abdominal exam: fundal height, tenderness, fetal movement]
- [Pelvic exam: cervix, vaginal findings]
- [Extremities: edema]
- [Other relevant findings]

Obstetric Ultrasound:
(hyphenated list)
- [Gestational age by ultrasound]
- [Fetal presentation]
- [Fetal heart rate]
- [Amniotic fluid index]
- [Placental location]
- [Fetal anatomy findings]
- [Other relevant findings]

Laboratory and Investigations:
(hyphenated list)
- [CBC, blood type, antibody screen]
- [Urinalysis]
- [Other relevant labs or imaging]

Assessment & Plan:
[One-sentence patient summary including age, gravida/para, gestational age, and primary diagnosis or concern]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Treatment plan]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]