INJX:
I am concerned about the fine lines around my eyes and want to look more refreshed. I'm also interested in lip enhancement.
MEDICAL:
No recent vaccinations. No active infections.
Allergies: No known allergies.
Medications: None.
ASSESSMENT:
Client presents with mild to moderate periorbital rhytids and a desire for lip augmentation. Examination reveals no contraindications to treatment. Skin appears healthy and well-hydrated.
TREATMENT:
Administered 20 units of Botulinum Toxin Type A to the periorbital region via subcutaneous injection. Client tolerated the injections well. 1ml of Hyaluronic acid filler was injected into the lips using a retrograde linear threading technique. Ice was used to minimise discomfort.
COST: $600
On-going Plan:
Recommend a follow-up appointment in two weeks to assess the results of the Botulinum Toxin and lip filler. Discussed the potential for further treatments to address other areas of concern.
Aftercare & Review:
Instructed client to avoid strenuous exercise for 24 hours and to avoid touching or massaging the treated areas. Advised client to contact the clinic if any adverse reactions occur. Scheduled a review appointment for 15 November 2024.
Social:
Client mentioned they are going on holiday next month.
Nurse Sarah Jones, RN
INJX:
[Client’s subjective concerns about ageing, appearance, skin, or goals for treatment today] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write in full sentences from the client’s perspective.)
MEDICAL:
[Relevant medical history including recent vaccinations or active infections] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as single line statements.)
Allergies: [Known allergies, including type of reaction] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as single line statements.)
Medications: [Current medications including dose and frequency] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as single line statements.)
ASSESSMENT:
[Clinician observations about the client and the treatments required] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write in full sentences from clinician perspective.)
TREATMENT:
[Treatment details including areas treated, method of administration, dosages/units used, tolerance, and use of ice or distraction tools] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write in full sentences from clinician perspective.)
COST: [Cost of treatment in $] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely.)
On-going Plan:
[Future treatment planning for skin, injectable treatments, or products] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write in full sentences.)
Aftercare & Review:
[Aftercare instructions provided, e.g., activity restrictions, skin care precautions, timing of review] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write in full sentences.)
Social:
[Personal or social information discussed that is unrelated to treatment, e.g., family, lifestyle, social plans] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as single line statements.)
[Clinician name and credentials]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use line-by-line text formatting. Do not insert blank lines between sections.)