Gynecology Problem Visit Note (Focused)

Date: [Date]

Patient: [Patient name and identifier]

Provider: [Provider name and credentials]

Visit Type: Problem-focused gynecology visit

Setting: [clinic / office / telehealth]

Chief Complaint & History of Present Illness

[Chief complaint in patient's own words]

[Focused HPI narrative] (Describe onset, duration, location, severity, quality, provoking/relieving factors, associated symptoms, and any attempted treatments with response. Include complaint-appropriate red-flag screening. Include only gynecologic context relevant to the complaint.)

Reproductive/pregnancy status: (Do not assume; explicitly state and plan to clarify if unknown.)

• [LMP: date / unknown]
• [Contraception method if relevant / none]
• [Pregnancy test: result / ordered / deferred with rationale]

[Pertinent gynecologic context] (Include only elements affecting today's differential: menstrual pattern, relevant OB history, IUD/implant status, prior relevant diagnoses or surgeries.)

Relevant History

[Pertinent medical history] (Include only items affecting today's assessment, e.g., coagulopathy, thyroid disease, immunosuppression.)

[Pertinent surgical history] (Pelvic/abdominal procedures relevant to the complaint.)

[Current medications] (Emphasize hormones, anticoagulants, and complaint-relevant medications.)

[Allergies and reaction types] (If unknown and prescribing anticipated, note plan to verify.)

[Family/social history] (Include only if directly relevant to clinical reasoning.)

Review of Systems

[Pertinent positives and clinically significant negatives] (Focus on constitutional, GI, GU, gynecologic, and complaint-specific domains. Omit systems not assessed. If deferred due to acuity, state this.)

Objective

Vitals: [BP / HR / Temp / others as obtained]

Exam:

• [General appearance]
• [Abdominal exam findings] (Note tenderness location, guarding, rebound, masses.)
• [Other focused system findings as relevant]

Pelvic Exam: (If performed; if not performed, state "Pelvic exam not indicated" or "deferred" with rationale.)

• [Consent obtained: yes / patient declined after counseling]
• [Chaperone: name and role / patient declined after counseling]
• [Exam limitations if any]
• [External genitalia, speculum exam, bimanual exam findings] (For each component: document findings or state "not performed" with reason.)

Results & Testing:

• [POC tests and results] (Urine pregnancy, urinalysis, vaginal pH, wet mount/KOH as applicable.)
• [Specimens collected with anatomic source]
• [Labs/imaging ordered]
• [Pending results and communication plan]

Assessment

(Organize by clinical problem, highest-acuity first.)

[Problem 1]: [Working diagnosis or undifferentiated problem]

[Key supporting and contradicting findings; focused differential including can't-miss diagnoses; clinical reasoning]

[Problem 2]

(Include additional problems only as applicable.)

Plan

[Problem 1]

• [Diagnostics ordered with indication]
• [Treatment: medications with dose/route/duration; non-pharmacologic measures]
• [Counseling provided] (Medication instructions, partner treatment, sexual activity guidance as relevant.)
• [Follow-up timing and modality]
• [Return precautions with explicit red flags]
• [Results management: how, when, and who will communicate]

[Problem 2]

(Repeat plan elements for additional problems as applicable.)

(When safety-critical information is missing—pregnancy status, allergies, pelvic exam consent/chaperone—document explicitly with plan to clarify.)