GYNAECOLOGY

Consult Note
Inpatient Progress Note
OR Note

Gynaecology: Projects

NOTE TEMPLATES

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Friendly Reminders...

Always add date and time for your notes
Indicate your level of training ("CC3")
Indicate who you have reviewed with and their level of training ("reviewed with Dr. Bob, PGY2")

CONSULT NOTE

*Write these on the appropriate consultation sheet, hospital dependent. Please ensure you leave a little bit of space for your resident to write a note. Some sites require dictations in addition to written consult notes; make sure you document the important details you want to dictate.
*Review the case with the resident/fellow on your team. If they are busy for a long period of time (e.g. stuck in an OR or delivery) or if it’s urgent, reach out to the chief resident or staff if on call.
*Often helpful to bring a sticker with the patient’s health card number to give to your staff.

Referring MD:

Reason for referral:

ID: age, gender/sex, GTPAL, LMP

CC: bleeding, discharge, pain, etc

HPI:

Bleeding
- Quantify: How many pads? How often do you need to change? Need to double up? Flooding? Wake up in the middle of the night to change pad?
- Anemia symptoms: dizziness, syncope, chest pain, shortness of breath, extreme fatigue? Iron supplementation needed?
Discharge: smell, colour, associated symptoms (burning, vulvar pain, rash/lesions, bleeding), STI testing, sexual history
Pain history: OPQRST
4 D’s of endometriosis: dysmenorrhea, dyspareunia, dysuria, dyschezia
Pertinent ROS: Abdominal pain? Urinary symptoms? Fever? Diarrhea? N/V?
Last meal – if potentially surgical

Past Gyne Hx (if applicable – may already be covered in HPI depending on CC):

Menses: age of first period (menarche), LMP (first day of period), frequency, duration, heaviness, dysmenorrhea, regularity, specifically note timing associated with menstruation such as intermenstrual bleeding, post-coital bleeding
Sexual history *May not be required or appropriate for all patients. Ensure the setting is appropriate if you’re asking these questions.
- Current or past STI’s
- 6 P’s (people, pregnancy, protection, practices, past, and problems)
- Contraception: OCP, IUD, etc.
Pap smear: most recent result, any previous abnormal results
History of cysts or fibroids

Past OB Hx: if applicable, may not always be relevant

PMHx: Any chronic medical condition. Special note of history of fibroids, endometriosis, malignancy, etc.

PSHx: Special note of abdo/pelvic surgeries and procedures to the cervix (i.e. biopsies, LEEP)

FHx: Gyne problems, malignancies, Lynch Syndrome, BRCA

Social Hx: Smoking, alcohol, drug use

Medications: OCP, hormone replacement

Allergies

Physical Exam:

Vitals: postural if bleeding may be an issue
General appearance
Cardiac/Respiratory exam if applicable
Abdominal exam
Pelvic exam: speculum, bimanual exam, general inspection

Investigations: U/S, B-hCG, Blood group and screen, CBC, PTT/INR, urinalysis, vaginal/cervical swabs

Assessment: Differential diagnosis

Plan: More investigations, admission/discharge, treatment/ no treatment, outpatient referral, disposition

INPATIENT PROGRESS NOTE

ID: Post-op day (POD) #X [or post-admission day (PAD #X) if not post-op], procedure or diagnosis

Subjective:

Most important questions for meeting discharge criteria:
- Pain well controlled? Analgesia use (PCA or PO/IV meds)?
- Tolerating PO intake? (Diet - NPO, DAT, fluids); N/V?
- Voiding well? (spontaneously, to Foley)
- Passing flatus/BM?
- Ambulating? Calf swelling?
PVB, pad count, clots (if appropriate)
Symptoms of hypovolemia (dizzy, lightheaded etc)
Other problems e.g. CP, SOB…

Objective:

General, most recent vitals (*PEARL: The trend of vitals is important; document time of Tmax if patient has had previous fever, or HR max if previously tachycardic etc. Also note if there was a fever O/N as the last set of vitals might be from the morning.)
Chest: dyspnea? WOB? Wheezing? Equal bilateral air entry?
Abdo: soft/distended, guarding, tender, peritonitic signs?
Incision: clean & dry, etc.
Periphery: calves tender/edematous/erythema, etc.
Labs: Hb
Fluids In’s/Out’s: if applicable, if abdominal/pelvic drains or urinary Foley present

Assessment: Well POD# or differential diagnosis if problem exists

Plan:

Investigations e.g. CBC, CXR, US, CT, leg dopplers
Advance diet, encourage ambulation, d/c Foley, home

OR NOTE

ID:

Preoperative Diagnosis: (suspected diagnosis/ reason for surgery)

Postoperative Diagnosis: (suspected diagnosis after surgery, could be different than above)

Procedure: total hysterectomy, cystectomy, etc.

Surgeon: staff name

Assistants: fellow/resident/medical student

Anesthetist

Type of anesthesia: general vs. epidural vs. sedation

Findings:

Specimen:

Complications:

Blood loss:

Count correct?

Gynaecology: Files