Clinical notes
Gynecology Consult Note Template: History, Exam, and Plan
A gynecology consult note stands or falls on the histories a general review skips: menstrual pattern, contraception, sexual health, and prior gynaecologic history. This template follows Scribeberry's built-in Gynecology Consult, used by clinicians for abnormal bleeding, pelvic pain, and contraception referrals.
Gynecology Consult Note Template: History, Exam, and Plan
Ready to review- Visit details pulled in
- Letter drafted from the conversation
- Your review and signature
Key takeaways
- A gynecology consult note separates the five histories — gynaecologic, obstetric, menstrual, contraceptive, sexual — so none is silently skipped.
- Quantified bleeding, a documented β-hCG, and chaperone/consent recording make the note clinically and legally complete.
- Abnormal bleeding documented by PALM-COEIN communicates the working diagnosis in one line.
What is a gynecology consult note?
A gynecology consult note is a written document that records a specialist gynaecologic assessment: the presenting problem, gynaecologic, obstetric, menstrual, contraceptive, and sexual histories, a gynaecology-focused examination, related laboratory and imaging studies, and an assessment and plan. A gynecology consult template keeps those histories systematic, so abnormal uterine bleeding, pelvic pain, or contraception counselling is documented the same way at every visit.
The template below matches Scribeberry's built-in Gynecology Consult, one of the most-used specialty templates in Scribeberry. Histories that were not provided are marked Not Provided rather than assumed — a contraceptive history guessed wrong is a clinical error, not a shortcut.
Blank gynecology consult note template
Copy this structure into your EMR, or use it as the Gynecology Consult inside Scribeberry, where it fills in from the encounter itself.
Gynecology consult note
ID Chief Complaint (CC) History of Present Illness (HPI) Symptoms Past Medical History (PMH) Surgical History Family History Medications Investigations Labwork Past Gynecological History Obstetric History Menstrual History Contraceptive History Sexual History Social History Review of Systems (ROS) Physical Examination (Gynecological-focused) Laboratory and Imaging Studies (Gynecology-related) Assessment Plan
Example 1: Abnormal uterine bleeding
Gynecology consult example — heavy menstrual bleeding
Fictional example for illustration only. 38-year-old referred for heavy menstrual bleeding and fatigue.
ID: 38-year-old G2P2 referred for abnormal uterine bleeding. Chief complaint: 'My periods have become unmanageable.' HPI: 10 months of heavy regular menses, soaking a pad hourly on days 1–2, clots, flooding at work. Progressive fatigue and dyspnea on exertion. No intermenstrual or postcoital bleeding. Menstrual history: Menarche 12, cycles regular 28 days, 7 days flow (previously 5). LMP 12 days ago. Gynecological history: Normal Pap 1 year ago; no prior STIs; no fibroids known. Obstetric: Two vaginal deliveries. Contraceptive: Copper IUD placed 5 years ago, satisfied otherwise. Sexual history: Monogamous, no dyspareunia. ROS: No easy bruising, no galactorrhea, no hirsutism. Exam: Pale conjunctiva. Pelvic: uterus bulky, ~10-week size, non-tender; no adnexal mass. Speculum normal, IUD strings visible. Studies: Hb 92, ferritin 6, TSH normal, β-hCG negative. Pelvic ultrasound: two intramural fibroids, largest 4.2 cm; endometrium 9 mm. Assessment: Abnormal uterine bleeding — leiomyoma (PALM-COEIN: AUB-L) with iron-deficiency anemia. Plan: IV iron referral, tranexamic acid for menses, discuss definitive options (hormonal management vs surgical referral) at 6-week follow-up; repeat CBC after iron. Pregnancy test negative documented before tranexamic acid.
Example 2: Contraception counselling after contraindication
Second example — switching contraception
Fictional example for illustration only. 31-year-old with migraine with aura requesting ongoing contraception after her combined pill was stopped.
Chief complaint: Contraception counselling. HPI: Combined oral contraceptive discontinued by pharmacist/primary care after migraine with aura diagnosis. Wants reliable contraception, prefers not to think about it daily. No current partner change, no STI concerns. LMP 2 weeks ago, cycles regular. Menstrual history: Regular 29-day cycles, moderate flow, mild dysmenorrhea. Gynecological history: Normal screening, no procedures. Obstetric: G0. Contraceptive history: COC 6 years, no adverse effects other than migraine onset last year. Sexual history: One partner, condoms since pill stopped. Exam: BP 118/76, BMI 24. Pelvic exam deferred — not required for chosen method. Assessment: Migraine with aura — estrogen-containing contraception contraindicated. Plan: Options reviewed (hormonal IUD, copper IUD, implant, progestin-only pill, DMPA). Patient chose levonorgestrel IUD for lighter periods; insertion booked with pre-procedure instructions, β-hCG day of insertion, backup contraception ×7 days. Follow-up 6 weeks post-insertion or sooner for pain, fever, or missing strings.
How to write a gynecology consult note, step by step
- Name the referral question: bleeding, pain, mass, contraception, or screening abnormality.
- Characterize the symptom precisely — for bleeding, quantify pads/tampons, clots, flooding, and cycle regularity.
- Take the five histories separately: gynaecologic, obstetric, menstrual (including LMP), contraceptive, and sexual.
- Ask the ROS that changes management: bruising, galactorrhea, hirsutism, urinary and bowel symptoms.
- Perform and document a focused pelvic exam, noting uterine size, tenderness, and adnexal findings.
- Attach the studies that settle the question: β-hCG, CBC/ferritin, TSH, and ultrasound findings.
- State the assessment using a classification where one exists (e.g., PALM-COEIN for abnormal bleeding).
- Make the plan actionable: treatment started, options discussed, and a dated follow-up.
Abnormal bleeding: PALM-COEIN at a glance
| Group | Causes | Structural? |
|---|---|---|
| P — Polyp | Endometrial or cervical polyps | Yes |
| A — Adenomyosis | Endometrial tissue in myometrium | Yes |
| L — Leiomyoma | Fibroids | Yes |
| M — Malignancy | Hyperplasia or cancer | Yes |
| C — Coagulopathy | e.g., von Willebrand disease | No |
| O — Ovulatory dysfunction | PCOS, thyroid, perimenopause | No |
| E — Endometrial | Primary endometrial causes | No |
| I — Iatrogenic | Hormones, IUD, anticoagulants | No |
| N — Not classified | Other or undetermined | No |
Who uses a gynecology consult note, and when
Gynecologists, family physicians, and nurse practitioners write gynecology consult notes in referral clinics, primary care, and sexual-health services.
- Abnormal uterine bleeding and pelvic-pain referrals.
- Contraception counselling, including after contraindications arise.
- Cervical screening follow-up and colposcopy triage.
- Pelvic mass and imaging follow-up.
- Fertility, menopause, and vulvar-symptom assessments.
Documentation, privacy, and record-keeping in Canada
Gynecology notes document intimate histories and examinations, so consent and chaperone documentation matter as much as findings. Record the offer or presence of a chaperone for pelvic examinations, the β-hCG result where pregnancy changes management, and the specific histories (menstrual, contraceptive, sexual) in the patient's own terms. Canadian privacy law treats this information as highly sensitive: disclose only with consent and record who the note was shared with.
Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.
Common mistakes that weaken a gynecology consult note
- Menstrual history as 'regular' with no LMP, cycle length, or flow quantification.
- Contraceptive history missing when prescribing hormones or devices.
- No β-hCG documented before treatments where pregnancy matters.
- Pelvic exam findings with no chaperone or consent note.
- Bleeding described without PALM-COEIN or an equivalent classification.
- Options counselling ('discussed options') with no record of what was offered or chosen.
The signing checklist
Before signing: Is the reason for the encounter explicit? Are negatives that change management recorded? Does every diagnosis have a plan with an owner and a date? Are results, counselling, and follow-up documented — or only intended?
Using this template in Scribeberry
The five histories, captured for you
Choose Gynecology Consult in Scribeberry and the menstrual, contraceptive, and sexual histories land in their own sections, drafted from the conversation. Then Smart Push the note into your EMR and keep the visit moving.
Frequently asked questions
What should a gynecology consult note include?
Chief complaint and HPI, past medical/surgical/family history, the five gynaecologic histories (gynaecologic, obstetric, menstrual, contraceptive, sexual), ROS, a gynaecology-focused examination, related labs and imaging, and an assessment and plan.
What is PALM-COEIN?
The FIGO classification for abnormal uterine bleeding: structural causes Polyp, Adenomyosis, Leiomyoma, Malignancy, and non-structural causes Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not classified.
When should β-hCG be documented in a gynecology note?
For abnormal bleeding, amenorrhea, pelvic pain, and before starting treatments where pregnancy changes management. Document the result explicitly, including when negative.
Can Scribeberry generate this note automatically?
Yes. The built-in Gynecology Consult template follows this exact structure and drafts it from the recorded or dictated encounter, marking missing information as Not Provided instead of inventing it.
Should a chaperone be documented?
Yes. Record that a chaperone was offered and whether they were present for intimate examinations — a standard expectation of Canadian regulators.
Why quantify bleeding instead of writing 'heavy'?
Management thresholds (investigation, iron therapy, referral) turn on quantified loss — pads or tampons per day, clots, flooding, and duration — not adjectives.
References
- Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
- Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
- Personal Health Information Protection Act (PHIPA) — Government of Ontario
- Clinical practice guidelines — Society of Obstetricians and Gynaecologists of Canada (SOGC)
- Cancer information and screening resources — Canadian Cancer Society
Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.
