Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for the patient’s visit.
Use the patient’s own words whenever possible (e.g., “Heavy periods,” “Bleeding between periods”).
History of Present Illness (HPI)
Bleeding Pattern:
Describe the characteristics of the abnormal bleeding, including:
Onset (when did the abnormal bleeding begin?)
Duration (how long does the bleeding last?)
Frequency (how often does the bleeding occur?)
Amount (heavy, moderate, spotting)
Any associated symptoms (cramping, pelvic pain, bloating)
Menstrual History:
Document the patient’s usual menstrual cycle:
Length of cycle (average number of days between periods)
Duration of bleeding
Regularity (consistent or irregular cycles)
Last menstrual period (LMP) date
Past Medical History (PMHx):
Briefly mention any relevant past medical conditions, such as:
Uterine fibroids
Endometriosis
Pelvic inflammatory disease (PID)
Polycystic ovary syndrome (PCOS)
Bleeding disorders
Previous surgeries (hysterectomy, D&C)
Medications:
List all current medications the patient is taking, including hormonal contraceptives.
Social History (SHx):
Briefly mention relevant social factors that may influence bleeding patterns, such as:
Smoking history
Weight changes
Physical Examination
General: Assess overall health and appearance of distress.
Pelvic Examination:
Document findings including:
Appearance of the vulva and vagina
Size, shape, and mobility of the uterus and ovaries
Presence of any tenderness or masses
Cervical motion tenderness (CMT)
Assessment
Summarize the key findings from the history and physical examination.
Formulate a differential diagnosis for the abnormal uterine bleeding, considering possibilities like:
Anovulatory bleeding
Hormonal imbalance
Uterine fibroids
Endometriosis
Pelvic inflammatory disease (PID)
Polycystic ovary syndrome (PCOS)
Bleeding disorders
Pregnancy complications (if applicable)
Cancer (less likely)
Plan
Outline the next steps in the patient’s management. This may include:
Diagnostic Tests:
Mention any planned tests to confirm the diagnosis, such as:
Urine pregnancy test
Complete blood count (CBC)
Blood tests for hormone levels (estrogen, progesterone)
Endometrial biopsy
Pelvic ultrasound
Treatment:
Depending on the diagnosis, treatment options may include:
Hormonal therapy (birth control pills, progesterone)
Non-hormonal medications to regulate bleeding
Minimally invasive procedures (uterine artery embolization, endometrial ablation)
Surgery (myomectomy for fibroids, hysterectomy)
Patient Education:
Educate the patient about the likely cause of the bleeding and management options.
Discuss potential risks and benefits of treatment options.
Follow-Up:
Schedule a follow-up appointment to discuss test results and treatment plan.
Additional Considerations
Adapt this template based on the specific details of the patient’s presentation.
Use clear and concise language while maintaining medical accuracy.
Document any discussions or shared decision-making with the patient regarding the plan.
This template provides a framework for documenting progress notes for patients experiencing abnormal uterine bleeding. Remember to tailor it to your specific workflow and facility’s documentation standards.