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Lactation Consultant

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BFC - KM - Patient Instructions

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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

Family Instructions: [Current date here (day- non-numeric month - year)] (do not include time of visit)

Please note that there may be spelling errors in the summary below, as this note was created with the help of AI. If you have any questions or concerns, please email your provider directly. Emails can be found on our website under the contact section. Thank you!

(Please write down any instructions provided to the family, remind families of handouts sent via Medeo, date of next appointment and any products they need to purchase or action items to do before next visit. Do not need to include the name of the pharmacy to which the medications may have been sent. You don't need to summarize their current feeding challenges; instead, focus on what we are doing moving forward. Please use bullet points to make it easier to read. Please make note if any invoice is due and to pay it via EMT (directions found on the invoice provided)

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AK

Dr. Anna Kowalska

Gynecologist, Poland

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