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Obstetrician & Gynaecologist Template

Obstetric Consultation Note

A professional Obstetrician & Gynaecologist template for healthcare professionals.
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About this template

Streamline your clinical documentation with our Obstetric Consultation Note template, perfect for busy Obstetricians and Gynaecologists. This comprehensive template ensures all essential information from antenatal appointments is meticulously captured, from current pregnancy details and gestational age to detailed obstetric and gynaecological histories. It efficiently organises investigations, medication records, and allergy information, ensuring nothing is overlooked. Utilising an AI medical scribe like Heidi with this template means patient data is accurately transcribed from consultations, helping clinicians maintain thorough and precise records with ease. Enhance patient care and practice efficiency with this invaluable tool for every obstetric and gynaecology consultation.

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Obstetric Consultation Note Plan Discussed management plan including continuation of current medications and diet recommendations. Follow-up appointment scheduled for 1 December 2024. Referral to dietician for gestational diabetes management. Age 32 Weight 75 kg Height 165 cm Current Pregnancy Gestation 28 weeks and 3 days Earliest scan 12 January 2024, showing a singleton pregnancy with estimated due date of 19 July 2024. 1st AN blds Blood Group: A+, Rhesus: Positive, HIV: Negative, Syphilis: Negative, Hepatitis B: Negative, Rubella Immunity: Positive, Full Blood Count: Normal, RPR/VDRL: Negative, Glucose testing: Elevated, consistent with gestational diabetes. Complications to date Gestational diabetes diagnosed at 26 weeks. Occasional mild abdominal pain reported, resolved spontaneously. No vaginal bleeding. Investigations First trimester screening (private sector) - low risk for aneuploidy. Glucose tolerance test (public sector) - confirmed gestational diabetes. Anatomy scan at 20 weeks (private sector) - normal fetal anatomy. Urine analysis - no proteinuria. Obstetric history G2P1. One live birth (vaginal delivery at term, no complications). One miscarriage at 8 weeks (spontaneous, no surgical intervention). Gynaecology history Menarche at 13 years, regular 28-day cycles. No history of fibroids or PCOS. No prior hormonal therapy. No prior gynaecological surgical procedures. Cycle prior to pregnancy Regular 28-day cycles, moderate flow. Smear 15 March 2023, normal, no HPV detected. Gynaecology issues No ongoing or past gynaecological conditions. Abdo infxn/surgeries Appendectomy at age 16. No history of abdominal infections. Medications Folic acid 400mcg daily (since pre-conception), Iron supplement 60mg daily, Prenatal multivitamin daily. Metformin 500mg twice daily (started after gestational diabetes diagnosis). Allergies Penicillin (rash). No known food or other allergies.
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Specialty

Obstetrician & Gynaecologist

Used

20 times

Type

Note

Last edited

21/01/2026

Created by

Heidi Team

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