Specialties
AI scribe for OB/GYN clinics
An OB/GYN note carries two histories a general template has nowhere to put. Notermed’s OB/GYN format records gravidity and parity as stated, prior deliveries by mode, gestational age and complications, and current pregnancy dating with gestational age and EDD; then the gynecologic history: last menstrual period and cycle pattern, contraception, Pap and HPV history, STI history, and prior GYN surgery, fibroids, endometriosis or cysts. Results include hCG, CBC, glucose screen, GBS, Rh, the STI panel, Pap and HPV, and ultrasound with the impression preserved.
- Built-in formats1
- Sections across them13
- Structure reviewed
What an OB/GYN note captures
Every line below is a field in the built-in OB/GYN format. The draft fills a line only when the visit spoke to it; a section with nothing stated is left out rather than padded.
- 01
Chief Complaint
- The primary reason for the visit, as stated
- A GYN concern, an annual exam, or a prenatal visit
- 02
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
- 03
Obstetric History
- Gravidity and parity as stated
- Prior deliveries: mode, gestational age, complications
- Current pregnancy dating, gestational age and EDD as stated
- 04
Gynecologic History
- Last menstrual period and cycle pattern
- Contraception
- Pap and HPV history
- STI history
- Prior GYN surgery, fibroids, endometriosis, cysts
- 05
Past Medical History
- Conditions and surgeries outside the OB and GYN history
- 06
Medications
- Dose, frequency, and duration
- Including prenatal vitamins and contraceptives
- 07
Allergies
- Drug allergies and reactions
- Latex, where stated
- 08
Social History
- Smoking, alcohol, substance use
- Occupation and relevant home situation
- 09
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
The format
One built-in format
Questions from OB/GYN clinics
- Does it keep the obstetric and gynecologic histories separate?
- Yes. Obstetric History captures gravidity and parity as stated, prior deliveries (mode, gestational age, complications) and current pregnancy dating with gestational age and EDD. Gynecologic History is its own section.
- What goes in the gynecologic history?
- Last menstrual period and cycle pattern, contraception, Pap and HPV history, STI history, and prior GYN surgery, fibroids, endometriosis or cysts, each as stated during the visit.
- Which prenatal labs have a place in the format?
- hCG, CBC, glucose screen, GBS, Rh and the STI panel, plus Pap and HPV results and ultrasound findings with the report impression preserved as written.
- Can the format be changed for my clinic?
- You can add formats of your own, and save your own copy of any built-in one. The built-in one already carries the OB/GYN structure and vocabulary.
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.
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 it on one of your own OB/GYN visits
Bring a consultation. We will record it, show you the draft in your format, and tell you plainly if Notermed is not a fit yet.