OB/GYN Note: Structure and Sections
Obstetrics & gynecology visit note (GYN problem or prenatal). Notermed's built-in OB/GYN Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the OB/GYN Note contains
13 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Chief Complaint
- The primary reason for the visit, as stated
- A GYN concern, an annual exam, or a prenatal visit
- 2
History of Present Illness
- Onset, duration, and character
- Bleeding pattern: amount and timing
- Pain: location, severity, relation to the cycle
- Associated symptoms
- Prenatal: interval symptoms and fetal movement
- Prenatal: contractions, bleeding, leaking of fluid
- 3
Obstetric History
- Gravidity and parity as stated
- Prior deliveries: mode, gestational age, complications
- Current pregnancy dating, gestational age and EDD as stated
- 4
Gynecologic History
- Last menstrual period and cycle pattern
- Contraception
- Pap and HPV history
- STI history
- Prior GYN surgery, fibroids, endometriosis, cysts
- 5
Past Medical History
- Conditions and surgeries outside the OB and GYN history
- 6
Medications
- Dose, frequency, and duration
- Including prenatal vitamins and contraceptives
- 7
Allergies
- Drug allergies and reactions
- Latex, where stated
- 8
Social History
- Smoking, alcohol, substance use
- Occupation and relevant home situation
- 9
Family History
- Breast, ovarian, or uterine cancer
- Clotting disorders
- Congenital conditions
- 10
Physical Examination
- Vital signs
- Abdominal findings
- Pelvic and speculum findings
- Prenatal: fundal height, fetal heart rate, presentation
- 11
Results
- Labs: hCG, CBC, glucose screen, GBS, Rh, STI panel
- Pap and HPV results
- Ultrasound findings, with the report impression preserved
- 12
Assessment
- The impression the clinician stated
- Prenatal: the pregnancy status line as stated
- A differential, only where one was verbalized
- 13
Plan
- Tests ordered
- Procedures performed or scheduled
- Prescriptions with strength and instructions as stated
- Contraception plan as stated
- Prenatal schedule and next-visit interval as stated
- Referrals
- Delivery-planning discussion, where actually held
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the OB/GYN Note
What sections does the OB/GYN note contain?
Thirteen: Chief Complaint, History of Present Illness, Obstetric History, Gynecologic History, Past Medical History, Medications, Allergies, Social History, Family History, Physical Examination, Results, Assessment and Plan.
Does one format cover both prenatal and gynecologic visits?
Yes, and it produces only the parts the visit supports. The history records the bleeding pattern and pain for a gynecologic concern, and interval symptoms, fetal movement, contractions, bleeding or leaking of fluid for a prenatal one.
What is recorded about the pregnancy?
Gravidity and parity as stated, prior deliveries with mode, gestational age and complications, and the current pregnancy dating with gestational age and EDD as stated. The examination adds fundal height, fetal heart rate and presentation where they were taken.
Is the note part of the chart as soon as the visit ends?
No. The draft is waiting for you when the visit ends, and it stays a draft outside the record until you review it and sign it.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the OB/GYN Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.