In gynecological care, precise and comprehensive clinical documentation is crucial for effective patient management and continuity of care. A well-structured prenatal consult note ensures that all pertinent information is captured, facilitating seamless communication among healthcare providers. Below, we provide a detailed walkthrough on how to write and format a prenatal consult note using a standardized template.

Patient Introduction

Begin with an introduction that includes patient demographics and the reason for referral. This section should provide a succinct overview, as seen in the example:

Example: Thank you for your referral of Jane Doe, a 28-year-old Gravida 2, Para 1 at 20 weeks gestation. Her Estimated Date of Confinement (EDC) is March 15, 2024, by first trimester ultrasound, done at 12 gestational weeks. She was referred due to elevated maternal BMI and gestational diabetes.

This Pregnancy

Detail current pregnancy-specific issues. This should include any complications or concerns:

Example: Elevated maternal BMI, gestational diabetes.

Past Obstetrical History

Include any relevant past pregnancy details, which may impact current care:

Example: Previous pregnancy complicated by preeclampsia.

Medical History

Document the patient's medical history comprehensively, including chronic conditions, medications, and surgical history:

Example: Hypertension, prenatal vitamins, no known drug allergies, appendectomy in 2015, history of HPV, last pap normal in 2022.

Social History

Capture social determinants of health that might influence care:

Example: Non-smoker, occasional alcohol use, software engineer, supported by partner and family, lives in urban community.

Physical Examination

Record vital signs and pertinent physical examination findings:

Example: Blood pressure: 130/85 mmHg, heart rate: 78 bpm, weight: 180 lbs, height: 5'6", BMI: 29. Symphysis fundal height: 20 cm, cephalic fetal presentation, fetal heart rate: 150 bpm.

Prenatal Investigations

Document lab results and screenings that are relevant to the pregnancy:

Example: Blood type: O+, Rh factor: positive, hepatitis B: negative, hepatitis C: negative, HIV: negative, syphilis: negative, rubella: immune, varicella: immune, GBS: pending, complete blood count: normal. Maternal serum screen: low risk. Urine tests: normal. EDS score on Edinburgh PPDS: 5.

Ultrasounds

Include ultrasound findings that provide insight into fetal development and pregnancy progress:

Example: Ultrasound on October 1, 2023, at 20 weeks gestation, findings: cephalic presentation, anterior placenta, normal anatomy, estimated fetal weight in 50th percentile, normal amniotic fluid, BPP score: 8/8.

Vaccination

Discuss vaccinations pertinent to pregnancy:

Example: We discussed the vaccines recommended in pregnancy, including Tdap, influenza, and Covid. Patient is interested and will receive them at the next visit.

Impression

Provide a clinical impression based on the findings:

Example: High-risk pregnancy due to gestational diabetes and elevated maternal BMI.

Plan

Outline the management plan and follow-up care:

Example: I will assume this patient's care with shared care from the referring physician. We discussed the obstetrical call system and reviewed that we work in a teaching hospital. Follow-up appointment in 4 weeks. Recommended lifestyle modifications: balanced diet and regular exercise. Continue prenatal vitamins. Referral to a nutritionist for gestational diabetes management.

Thank you again for involving me in her care.

While manual documentation is thorough, it can be time-consuming. This is where AI medical scribes like Notis AI Medical Scribe revolutionize the process for gynecologists. By leveraging advanced voice-to-text technology, Notis transcribes patient interactions into structured SOAP notes, significantly reducing the time spent on documentation.

Benefits for Gynecologists

Notis AI Medical Scribe is designed to enhance efficiency and accuracy in clinical documentation. With features such as WhatsApp integration, high transcription accuracy, and multilingual support, it allows healthcare providers to focus more on patient care rather than administrative tasks. This means gynecologists can save up to 2 hours per day, reducing burnout and enhancing productivity.

By automating patient charting, Notis ensures that clinical notes are not only comprehensive but also easily retrievable, improving the overall patient documentation process. This tool is indispensable for any gynecologist looking to streamline their workflow and improve patient care outcomes.