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Obstetrics Triage Note
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Gotowa notatka
Przykład — wygenerowany przez Notat na podstawie przykładowej wizyty
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.
Szablon
ID: [Patient name] is a [Age] [Gravida/Para status] at [Gestational age] Chief Complaint: [Chief complaint] History of present illness - [History of present illness] - [Contractions] - [Leakage of fluids] - [Vaginal bleeding] Current pregnancy: (hyphenated list) - [Pregnancy conception method: Spontaneous/IVF] - Gestational diabetes: [Yes/No] - Hypertension: [Yes/No] - Serologies [protective/non-protective] - Rubella: [Immune/Non-immune] - Hepatitis B: [non-reactive/reactive] - Hepatitis C: [non-reactive/reactive] - HIV: [non-reactive/reactive] - Syphillis: [non-reactive/reactive] - G/C: [negative/positive] - GBS: [negative/positive] - Blood type: [Blood type], Rh: [positive/negative] - FTS: [Low risk/Other] - Anatomy U/S: [Normal/Abnormal, placenta location] - Last U/S: [Date and findings] Ob Hx: (hyphenated list) - [Obstetrical history details: previous pregnancies, outcomes, complications] PMHx: [Past medical history] SHx: [Social history] Meds: [Current medications] Allergies: [Allergies] O/E: (hyphenated list) - [Vital signs] - Abdomen: [Findings] - Vaginal: [Findings] - Speculum: [Findings] - FHR: [Fetal heart rate] - Toco: [Tocometry findings] A/P: [Age] [Gravida/Para status] at [Gestational age] presenting with [...]. [Primary diagnosis], - [Investigations planned or ordered] - [Treatment plan] - [Counselling discussion] - [Referrals sent] - [Follow up plan] - [Return precautions]
Udostępnione przez
PN
Dr. Priya Nair
Pediatrician, Singapore
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