4,023 uses
Maternal Fetal Medicine 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
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]
Shared by
MB
Dr. Marc Beaulieu
Family Physician, Canada
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
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