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OB/GYN Problem Visit Note Chief Complaint - Primary gynecologic concern in patient's words when possible. History of Present Illness - Onset, duration, severity, pattern, associated symptoms, and prior treatments/response. - For bleeding: cycle length/flow, intermenstrual/postcoital bleeding, clots, soaking, and impact on activity. - For pain: location, relation to menses, dyspareunia, urinary/GI symptoms. - For discharge/itching: color, odor, irritants, partners, and self-treatment. Gynecologic / Obstetric / Sexual History - LMP, contraception, Pap/HPV history, STIs, pregnancies/outcomes, menopause status if relevant. - Sexual history and safety as appropriate to the visit. Medications / Allergies / Relevant PMH - Hormonal therapies, anticoagulants, relevant medical and surgical history. Exam - Focused exam as performed (abdomen, external genitalia, speculum, bimanual, breast if indicated). - Document chaperone use if applicable. Data / Procedures Today - Pregnancy test, wet mount, STI testing, ultrasound, endometrial biopsy, IUD/implant procedures, or other in-office procedures with findings. Assessment - Working gynecologic diagnosis/differential. Plan - Medications, procedures, imaging, referrals, contraception plan, and follow-up. - Patient counseling and return precautions.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Keeps menstrual, obstetric, sexual, and contraceptive history easy to capture when relevant.
- Supports focused exam and shared decision-making for procedures and meds.
- Works across acute GYN complaints and chronic symptom follow-ups.
- Clean base for AI documentation in busy OB/GYN clinics.
- 1Gynecology problem-focused office visits
- 2Contraception and AUB evaluations
- 3Pelvic pain and vulvovaginal complaint visits
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Chief Complaint Heavy menstrual bleeding for 6 months with worsening fatigue. HPI Cycles q26–28 days, now soaking through super tampon hourly for first 2 days with clots. Mild cramping. No intermenstrual or postcoital bleeding. Tried ibuprofen with partial help. Denies pregnancy desire for ≥2 years. GYN History G1P1. Mirena removed 1 year ago. Pap 2024 NILM/HPV−. No known fibroids. Exam Abdomen soft, nontender. Speculum: cervix normal, moderate blood in vault day 2 of menses. Bimanual: 8-week boggy uterus, nontender; no adnexal mass. Data Today Urine hCG negative. CBC pending. Office TVUS: 14-week-sized uterus with two intramural fibroids (4 cm, 3 cm), endometrium 8 mm. Assessment Abnormal uterine bleeding—heavy menstrual bleeding, likely fibroid-related; rule out anemia. Plan CBC/ferritin; start tranexamic acid during menses and scheduled NSAID. Discussed medical options vs myomectomy/UAE/hysterectomy; patient prefers medical trial first. Iron supplementation if anemic. Follow up 6 weeks with labs; sooner for soaking through protection hourly for >2 hours, syncope, or severe pain.
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