3,691 uses
Fetal Medicine Consultation Note
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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
Fetal Medicine Specialist Note Patient Identification: [Patient name, age, gravida/para status, gestational age, presenting concern] History of Present Pregnancy: [Summary of current pregnancy, including gestational age, conception method, relevant symptoms, and reason for referral] [Details of any complications, abnormal findings, or screening results] Obstetric History: (hyphenated list) - [Gravida, para, abortions, living children] - [Details of previous pregnancies, including outcomes, complications, mode of delivery, gestational age at delivery] Past Medical History: (hyphenated list) - [Relevant maternal medical conditions] - [Surgical history] - [Genetic or inherited conditions] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Prenatal vitamins, supplements] Allergies: (hyphenated list) - [Drug, food, or environmental allergies] - [Reaction type] Family History: (hyphenated list) - [Relevant genetic or congenital conditions] - [Maternal and paternal family history] 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] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General maternal exam findings] - [Abdominal exam: fundal height, fetal lie, presentation, tenderness] - [Other relevant system findings] Ultrasound Findings: (hyphenated list) - [Gestational age by ultrasound] - [Fetal biometry: measurements and percentiles] - [Amniotic fluid index] - [Placental location and appearance] - [Fetal anatomy survey: findings] - [Doppler studies: umbilical artery, MCA, ductus venosus] - [Any abnormal findings] Investigations: (hyphenated list) - [Laboratory results: CBC, blood group, serologies, etc.] - [Genetic testing results] - [Other imaging or diagnostic studies] Assessment & Plan: [One-sentence summary including maternal age, gestational age, and primary fetal/maternal diagnosis] #) [Assessment as a numbered item if multiple issues] (hyphenated list with each corresponding plan item on a new line) - [Further investigations planned or ordered] - [Treatment plan: medical, surgical, or procedural interventions] - [Counselling provided: prognosis, options, risks/benefits] - [Referrals to other specialists or services] - [Follow up plan: timing, location, purpose] - [Return precautions]
Shared by
AB
Dr. Amalie Berg
General Practitioner, Norway
How it works in Notat
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