Well-Woman/Gynecologic Preventive Visit Note

Date: [date]

Patient: [name, DOB, age]

Provider: [provider name/role]

Visit Type: Preventive gynecologic visit

Chaperone: [offered and present / offered and declined / not applicable] [chaperone name/role if present]

History

[Reason for visit and patient goals. Interval events since last preventive visit including new diagnoses, surgeries, or gynecologic symptoms. Current menstrual status with LMP or menopausal status. Obstetric history. Cervix/uterus status if surgically altered. Current contraception and reproductive intentions if applicable. Relevant PMH affecting screening decisions. Family history of breast/ovarian cancer if positive. IPV screening result.] (Use 1–2 brief paragraphs. If patient declines detailed sexual history or has no interval changes, document that topics were offered and state "declined" or "no changes." Do not fabricate negative findings.)

[Confidential adolescent/young adult portion if applicable: offered/completed status]

Preventive Services Status

(For each item, include last date/result if known and action today: performed, ordered, deferred with brief reason, or not due. If managed by PCP, note "coordinated with PCP." If records unavailable, document "records requested.")

• Cervical screening: [last test type, date, and result] — [action today including specimen type if collected, or reason deferred/not due]
• Breast screening: [mammogram status and next due date] — [action today; shared decision notes if applicable]
• STI screening: [tests ordered/performed with anatomic sites, or reason not indicated]
• Immunizations: [vaccines due and administered today / up to date]
• Other screenings: [depression screen result; other relevant screens]

Objective

Vitals: [BP, weight/BMI, other relevant vitals]

General exam: [pertinent findings from general, thyroid, cardiac, abdominal exam as performed] (Only include elements actually examined.)

Breast exam: [Performed / Deferred]

[If performed: consent obtained, chaperone present with name/role, and brief findings including symmetry, masses, skin changes, nodes. If deferred: one-sentence shared decision rationale.] (When exam is not performed, omit findings entirely. If performed and chaperone or consent documentation is missing, flag for completion—do not infer.)

Pelvic exam: [Performed / Deferred]

[If performed: consent obtained, chaperone present with name/role, indication for exam, and brief findings for components performed including external, speculum with cervical appearance, bimanual. Note specimen collected if applicable. If deferred: "Pelvic exam deferred—shared decision; no symptoms requiring exam" or "patient declined."] (When exam is not performed, omit findings entirely rather than noting normal. If performed and chaperone or consent documentation is missing, flag for completion—do not infer.)

Assessment and Plan

1. Preventive care/health maintenance: [Key risk factors. Screening actions taken today. Pending results and communication plan. Return interval for routine care.]
2. Contraception/reproductive plan: [Methods discussed, patient priorities, decision made, counseling content including effectiveness tiers.] (Include only if applicable.)
3. Additional concerns: [Assessment and plan for any non-preventive problems addressed.] (Include only if non-preventive problems were addressed. Keep distinct from preventive content.)

Orders: [labs / imaging / prescriptions / referrals]

Follow-up: [timing for routine care and result review] [return precautions if clinically appropriate]