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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Gynaecology

Document Title

: Gynaecology Outpatient Assessment Form

PRESENTING PROBLEMS

Problem List

Follow Up Information

Place Of Review

Date Of Last Follow-Up

Last Menstrual Period (LMP)

Last Working Diagnosis

Treatment / Management / Surgery

PATIENTS PROGRESS

Patient's Condition

Problems With Provided Treatment

Follow-Up Examination Comments

Comments On Progress

RESULTS REVIEW

Comments On Investigations

Comments On Ultrasound

Comments On Hpe

DIAGNOSIS

Diagnosis

Concurrent Illnesses

Co-Morbidities

Associated Problems

Risk

LowHigh

Comments

MANAGEMENT

Plan

Admission

Readmission

Discharge

DAMA

Home leave

Medical leave

For ultrasonography next F/Up

For day-care surgery

For elective Gynae operation

For review of investigations

Follow up with own doctor

Follow up with referring clinic

For office colposcopy

For office hysteroscopy

Regular fetal assessment

For Blood Sugar Profile

For Family Planning advice

Surgical evacuation of uterus

Medical evacuation of uterus

Termination of pregnancy

Genetic counselling

Prenatal counselling

Others, specify

Comments

REFERRAL

Outgoing

Comments

Orders

Others, Specify

DISMISSAL ARRANGEMENT

Follow Up Appointment

Please Update Method

Appointment

SIGNATURES

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