SUBJECTIVE:
Pain and Other Symptoms:
Mr. Jones reports that his lower back pain has improved from a 7/10 to a 4/10 since his last visit. He also notes a reduction in the frequency of his leg pain.
General:
Mr. Jones shared that he is feeling more optimistic about his recovery and has been enjoying spending time with his grandchildren. He also mentioned he is feeling less stressed at work.
Mr. Jones responded well to the previous treatment, reporting a noticeable decrease in pain and an increase in mobility.
Mr. Jones is scheduled for a follow-up appointment in two weeks.
Laboratory and imaging results: No new imaging or lab results were discussed.
New Symptoms:
Mr. Jones denies any new pain or symptoms.
REVIEW OF HOMEWORK:
Mr. Jones reports he has been consistently performing the exercises provided and has noticed a positive impact on his pain levels. He has also been reading the provided educational materials.
Mr. Jones has been applying activity management strategies by taking regular breaks during his work day.
Mr. Jones has started going for short walks in the evenings.
Mr. Jones stated that he now understands that pain is not always an indicator of damage.
PATIENT CONCERNS:
Mr. Jones is concerned about returning to work full-time and how to manage his pain while working.
AGREED FOCUS FOR THIS APPOINTMENT:
We agreed to focus on strategies for managing his pain at work and adjusting his activity levels.
OBJECTIVE MEASURES:
Physical examination revealed improved range of motion in his lumbar spine. Forward flexion is now at 60 degrees, an increase from 45 degrees at the last visit.
TREATMENT:
I provided feedback on Mr. Jones's progress, commending him on his consistent effort with his exercises and homework.
We discussed his therapy goals, which include returning to work and improving his overall quality of life.
The goals of therapy identified in the session are to reduce pain, increase function, and improve his ability to manage his pain.
We discussed the contributors to his pain, including prolonged sitting and poor posture. We also discussed pain science and pain management techniques.
We identified that prolonged sitting and stress are triggers for increases in his pain.
We discussed his pattern of reducing activity, and the negative consequences of this, which include increased stiffness and deconditioning.
I suggested that he incorporate regular breaks and gentle movement throughout the day to address his pattern of reducing activity.
We discussed his boom and bust pattern of overdoing activity, and the negative consequences of this, which include increased pain and flare-ups.
I suggested that he gradually increase his activity levels and avoid overexertion to address his boom and bust patterns.
We discussed activity management strategies, including chunking, task breakdown, task swapping, taking pauses or breaks, and working out baselines.
Mr. Jones stated that he thinks chunking and task breakdown would be difficult to apply at work due to the nature of his job.
Mr. Jones expressed concerns about task swapping, stating that it might not be feasible in his current work environment.
Mr. Jones stated that he is willing to try taking pauses or breaks at work.
Mr. Jones is willing to calculate and apply baselines.
I advised Mr. Jones to continue with his exercises, take regular breaks, and gradually increase his activity levels.
I provided Mr. Jones with a new set of exercises focusing on core strengthening and flexibility.
Mr. Jones was given a handout on activity pacing and a schedule for gradually increasing his activity levels.
Other specific treatments administered during the visit included manual therapy to his lumbar spine.
Mr. Jones expressed understanding of the homework and tasks.
PLAN:
Mr. Jones is scheduled for a follow-up appointment in two weeks. I will send a letter to his GP to update them on his progress.
SUBJECTIVE:
Pain and Other Symptoms:
[Describe progress in the pain and other symptoms which are the reason for treatment] (Only include if explicitly mentioned in the transcript, and only if related to the patient’s usual symptoms. Write in full sentences, using patient name or pronouns.)
General:
[Describe recent social, mood and health events expressed by the patient. Do not include pain.] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe the response to the treatment provided by me at the previous appointment] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe any future medical interventions or changes planned] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Laboratory and imaging results] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
New Symptoms:
[Describe new pain or symptoms] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
REVIEW OF HOMEWORK:
[Describe progress since last appointment on previously given homework (e.g. reading, exercises, tasks, relaxation)] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe application of activity management strategies and active self-management to daily tasks and employment since the previous appointment] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe new activities the patient has engaged in or increased engagement in since the previous appointment] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe any change in the patient’s understanding of pain which they reported] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
PATIENT CONCERNS:
[Patient’s concerns and thoughts about their condition, treatment, or progress] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
AGREED FOCUS FOR THIS APPOINTMENT:
[Describe patient and clinician aims for the appointment and what was agreed to focus on] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
OBJECTIVE MEASURES:
[Physical examination findings including range of motion] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
TREATMENT:
[Describe my feedback on pain progress and completion of homework] (Only include if explicitly mentioned in the transcript. Write in full sentences.)
[Describe the discussion about therapy goals] (Only include if explicitly mentioned in the transcript or clinical note. Write in full sentences.)
[Describe the goals of therapy identified in the session] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about contributors to pain, pain science, and pain management] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about identifying the contributors, triggers, or ingredients for increases and decreases in pain] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the clinical discussion about the patient’s pattern of reducing or avoiding activity] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the reasons the patient avoids or stops activity and the negative consequences of this] (Only include if explicitly mentioned. Write in full sentences.)
[Describe my suggestions to address the patient’s pattern of reducing or avoiding activity] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the clinical discussion about the patient’s boom and bust or overdoing activity patterns] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the reasons the patient engages in boom and bust (or overdoing) and the negative consequences of this] (Only include if explicitly mentioned. Write in full sentences.)
[Describe my suggestions to address the patient’s boom and bust (or overdoing) patterns] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the clinical discussion about activity management strategies, including chunking, task breakdown, task swapping, taking pauses or breaks, and working out baselines] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about chunking or task breakdown and why the patient said it would be difficult to apply at home or at work] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about task swapping and the patient’s concerns about applying it at home or at work] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about taking pauses or breaks, including the patient’s concerns about doing this at home or work] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the discussion about calculating and applying baselines, including the patient’s concerns about applying this at home or at work] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the advice I gave to the patient during the visit] (Only include if explicitly mentioned. Write in full sentences.)
[Describe exercises provided to the patient during the visit] (Only include if explicitly mentioned. Write in full sentences.)
[Describe homework, tasks, and self-management plans given to the patient to complete before the next appointment] (Only include if explicitly mentioned. Write in full sentences.)
[Describe other specific treatments administered during the visit] (Only include if explicitly mentioned. Write in full sentences.)
[Describe the patient’s response to the treatment delivered during the session, including whether the patient expressed understanding of the homework or tasks] (Only include if explicitly mentioned. Write in full sentences.)
PLAN:
[Describe the treatment plan, including communication with other health professionals, referrals, and follow-up appointments. Do not repeat items from the TREATMENT section.] (Only include if explicitly mentioned in the transcript or clinical note. Write in full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, leave the relevant placeholder or section blank. Use patient name or pronouns in every sentence. Never state that the patient understands a concept unless their own words or responses clearly show that they do.)
