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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
Endodontist Note Patient Identification: [Patient name, age, gender, relevant dental history, presenting complaint] History of Present Illness: [Description of chief complaint, onset, duration, character of pain or symptoms, aggravating/alleviating factors, previous dental treatments, relevant medical history] Past Dental History: (hyphenated list) - [Previous dental procedures] - [History of trauma] - [Previous endodontic treatments] - [Other relevant dental history] Medications: (hyphenated list) - [Medication name, dose, route, frequency] Allergies: (hyphenated list) - [Drug/other allergies or NKDA] Social History: (hyphenated list) - [Tobacco use: type, amount, duration] - [Alcohol use: type, amount, frequency] - [Occupation] - [Other relevant social factors] Clinical Examination: (hyphenated list) - [Vital signs if relevant] - [Extraoral findings: swelling, lymphadenopathy, tenderness] - [Intraoral findings: tooth number, caries, restorations, mobility, percussion/palpation tenderness, sinus tract, periodontal status] - [Pulp testing results: cold, heat, EPT] - [Radiographic findings: periapical radiolucency, root morphology, canal anatomy, other findings] Diagnosis: (hyphenated list) - [Tooth number: pulpal diagnosis (e.g., irreversible pulpitis, necrotic pulp)] - [Tooth number: periapical diagnosis (e.g., symptomatic apical periodontitis, chronic apical abscess)] Treatment Plan: (hyphenated list) - [Recommended endodontic procedure (e.g., root canal therapy, retreatment, apicoectomy)] - [Adjunctive treatments (e.g., antibiotics, analgesics)] - [Restorative recommendations] - [Patient counselling and consent] - [Referrals if needed] - [Follow up plan] - [Return precautions]
Shared by
CM
Dr. Claire Murphy
General Practitioner, Australia
How it works in Notat
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