ObGYN General consult

OVERALL_INSTRUCTIONS

(Always use abbreviations for terms such as "Pap" for Papanicolau test. Use abbreviations for lab parameters such as "TSH" for thyroid stimulating hormone, and use abbreviated forms of units of measure)

Chief Complaint

Patient Consultation Summary

Template

Thank you for asking me to see [name] for [chief complaint]. [ Include the sentence "She consented to have our visit using an AI scribe today".] [Sentence about date or year of LMP]. She is an [age] year old G[number of pregnancies]P[number of deliveries or children]. Her main concern is [ then Detail chief complaint and how long, details of symptoms and severity and treatments tried already.] She [is / is not] sexually active. [Contraceptive method please include in sentence format] [if she is virginal please write she is virginal or if contraception is not required,] [If she is having pain with sex include if this is superficial or deep dyspareunia and how long this has been occurring][If patient is not having sex for a specific reason that is stated, please include that reason] [Please include details of partner if this is a consult for infertility including name, age, occupation, social history and coital frequency] [If she complains about pain please include type of pain, for how long it has occurred and alleviating or exacerbating factors] [include below bullet points titled Pelvic floor inventory if this is a consult regarding pelvic organ prolapse or urinary incontinence as stated during HPI] [if consult does not relate to prolapse or voiding dysfunction please indicate whether bowel or bladder function are normal][if the visit has nothing to do with prolapse or incontinence then omit the bullet list.][If the patient is under 40 please dont use the bullet list.] [If the consult relates to menopause, please indicate details about hot flushes such as how often, how severe, night sweats and how often and how severe, sleep whether short or non restorative or interrupted and how they manage it, mood whether low and how they have managed it and whether they have seen a counsellor or specialist, and any previous treatment for menopause and how that was tolerated.] [If the conversation includes information about diet and exercise please include details here.] [If the conversation includes information about mood please include details here such as history of mood symptoms, current and previous treatments, triggers and current symptoms.] • Prolapse symptoms - [if the patient reports pelvic organ prolapse symptoms type (yes). If no prolapse symptoms insert (none)] • Stress incontinence - [if the patient reports stress incontinence symptoms type (yes). If no stress incontinence symptoms, insert (none)] • Lower urinary tract symptoms - [if the patient reports overactive bladder symptoms type (yes). If no overactive bladder symptoms, insert (none)] • Voiding dysfunction - [if the patient reports voiding dysfunction symptoms type (yes). If no voiding dysfunction symptoms type (none)] [If voiding symptoms of leakage or urgency then indicate the # of protective pads used daily and type, how many and type of caffeinated beverages she takes daily and how often she is up to the bathroom and any night voiding or wetting of bed] • Defecatory dysfunction - [if the patient reports bowel dysfunction symptoms type (yes). If no Bowel dysfunction symptoms, insert (none)] • Sexual dysfunction - [if the patient reports sexual dysfunction symptoms type (yes). If no Sexual dysfunction symptoms insert (none)] [if the chief complaint is infertility, please include the name and information about the partner, his name, age, paternity, health, smoking, marijuana and whether he has done a semen analysis and the results] PAST OBSTETRICAL AND GYNECOLOGICAL HISTORY: [document number of c-sections, ectopic pregnancies, miscarriages, vaginal deliveries, termination of pregnancies - surgical or medical] [document if has had tubal ligation or tubal removal, gynecological surgeries or STI's. If not discussed do not include.] PAST MEDICAL HISTORY: [bulleted list of medical problems] PAST SURGICAL HISTORY: (bulleted list of surgeries) MEDICATIONS: [multiple medications are listed on one line with comma also include any vitamins or supplements she is taking] ALLERGIES: (bulleted list and reaction if provided) SOCIAL HISTORY: [bulleted list of information on tobacco use, alcohol use, illicit drug use and occupation. Document any exposure to domestic violence or sexual assault or abuse if not history of abuse do not include. Document if she states she is a vegetarian.] FAMILY HISTORY: [bulleted list list breast, uterine, ovarian or colon cancer, osteoporosis, hereditary cancers or DVT, or other conditions that the patient brings up in family members] SCREENING: [write when of if pap is due or when it was last done] [write when and if mammogram is due or completed if over age 45, otherwise omit] [if over age 50 indicate whether she has had a FIT test or colonoscopy, otherwise omit] [if over 50 indicate whether she had the shingles vaccine, otherwise omit] INVESTIGATIONS: [labs, ultrasound, MRI] [if none write none, if tracing please write tracing which type of labs] [urine pregnancy test result if done please write as UPT negative or positive] EXAMINATION: [height] [weight] [calculate BMI based on height and weight:BMI = weight (kg) / [height (m)]^2] [Include BP if done] General exam is unremarkable. Head and neck, chest and CV exam are grossly normal. [enter breast exam if done] [enter Abdominal exam if done] Pelvic examination: [if pelvic examination deferred please state deferred either as not indicated or if patient declines] [If pelvic examination done please write External genitalia grossly normal or include any concerns on vulvar examination]. [if Q tip test done please include findings for sensitivity and where felt or if vulvodynia noted] Document if cervix appears normal [include any cervical concerns, or if not present and only vaginal vault noted]. Document if cough stress test was performed and if positive or negative, stage of prolapse including cystocele, rectocele, cervix/vault. Document presence of urethral hypermobility. Document Kegel exercise strength out of 5 if stated. Document if bimanual exam was done or not and include uterine size, anteverted, retroverted or axial. Document if there were no palpable adnexal masses or tenderness. [if mass or pain noted please include] Document if speculum was used. [If tests done include PAP test, HPV swab, liquid based cytology, vaginal or cervical swabs done] Document if medications were provided prior to procedure. If procedure completed state whether verbal or written consent was obtained. [If IUD was removed please indicate old IUD was removed] [mention here if I perform a procedure like iud insertion, endometrial biopsy, vulvar or cervical biopsy] [If IUD was inserted write this]: [Type of IUD, lot # and expiration date if mentioned] was inserted. Uterus sounded to [cm]. String cut 2-3cm from os. Document if patient tolerated the procedure well or if complications of procedure and what was done. Document if post care instructions were provided. SUMMARY AND PLAN: In summary this is a [ add age] year old patient with the following issues: [include assessment and plan by problem ] [only include gynecological issues or issues identified to follow up with their GP for, do not include non gynecological issues in the assessment or plan, do not include any codes for anxiety, depression, mood etc] [State if patient is booked for follow-up and when or if no follow-up is required or if she has been advised to contact me after results of her investigations] [If investigations have been ordered indicate that the patient should call to request follow up if she has not heard about the results within 1 month of the investigation] I will keep you abreast of her progress. Thank you for allowing me to care for your patient.