F/U Pelvic Health (Issues List)

"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session" Patient Information: - [name], Age: [age in years and months], [gender/sex] (Only include if explicitly mentioned in transcript, context or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank.) - Occupation: [occupation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Physical Activity: [physical activity details] (List physical activity, sports, exercise and frequency of these. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Present: [other persons present] (Note if there was any other person in attendance and their relationship to the patient. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [upcoming appointments] (Note any upcoming appointments with their specialist, e.g. gynaecologist, or with a member of their allied health team. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) --- Subjective: - Reason for visit: [chief complaints] (Mention reasons for visit, chief complaints such as requests, key symptoms etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [progress since last appointment] (Mention progress or worsening of complaint since last appointment. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [adherence to home exercises] (Mention adherence to home exercises and advice from last appointment. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Bladder Symptoms: [bladder symptoms] (List any symptoms related to bladder function including urinary frequency, nocturia, incontinence episodes, pad usage, and voiding function, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Bowel Symptoms: [bowel symptoms] (List any symptoms related to bowel function including bowel frequency, stool type, urgency, incontinence episodes, pad usage, defecation difficulties, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Prolapse Symptoms: [prolapse symptoms] (In female patients only: List any symptoms related to pelvic organ prolapse including feeling of vaginal bulge, vaginal heaviness, voiding dysfunction, defecation difficulties, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Sexual Symptoms: [sexual symptoms] (List any symptoms related to sexual function including erectile dysfunction, dyspareunia, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [completed investigations with results] (Only include completed investigations where results have been explicitly mentioned in transcript, context or clinical note. All planned or ordered investigations must be included under Plan, not here. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Patient Goals: - [short-term goals] (Short-term physiotherapy goals and time frame for achieving these goals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [long-term goals] (Long-term physiotherapy goals and time frame for achieving these goals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [progress towards goals] (Mention progress towards physiotherapy goals. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) --- Objective: PFM assessment: - [PFM examination findings] (Pelvic floor muscle examination findings in bullet point form. Note whether this was an internal vaginal examination, digital rectal examination, perineal palpation, trans-perineal ultrasound, or abdominal ultrasound. Note consent and positioning. Include findings on GH+PB, prolapse, strength, tone, relaxation, endurance/holds. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) MSK assessment: - [MSK examination findings] (Physical examination of gait, general movement, range of motion, and muscle testing of any muscles other than pelvic floor. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) --- Action Taken: (Repeat the following format for each issue, problem or request discussed during the session. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) [issue number. issue name] (Issue, request, topic or condition name only.) - [interventions] (Describe any interventions performed during the visit for this issue, including exercises and manual therapies. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) // [patient response] (Patient's response to interventions for this issue. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [education] (Patient education and counselling for this issue. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) --- Evaluation: [progress towards treatment goals] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Home Program: [home exercises and self-management] (Home exercises, stretches, and self-management strategies for all issues. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Handouts/Leaflets: [handouts given] (Any handouts, leaflets, or written patient education given to the patient physically or emailed to them. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) --- Plan: - Review: [next appointment] (When the patient is to come back again. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Letter: [referral letter] (Mention whether a letter needs to be written back to the referring doctor. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - Ongoing plan: (Repeat the following format for each issue discussed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [treatment planned] (Treatment planned for this issue. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) - [relevant referrals] (Relevant referrals for this issue, including referrals to other healthcare providers. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)