Physiotherapist's INITIAL(SF)

CURRENT CONDITION: - [DETAILED DESCRIPTION OF PRIMARY INJURY, PROBLEM, COMPLAINT OR SYMPTOM] (Always specify if it involves the LEFT (L) or RIGHT (R) side.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Date of onset or date of surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Description of how the injury occurred or complaint began] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Details of any prior therapy, interventions, and/or surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Describe progression of complaint and nature of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) PATIENT INFORMATION: - [Employment status, physical demands of job, work-related activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [General exercise and activity levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) Medical History: - [List existing and past medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Details of previous surgeries/treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Mention any allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Mention current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Mention relevant social history like lifestyle factors, including tobacco and alcohol use, that may affect therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Mention family medical history of disease that may impact therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) PATIENT GOALS: - [Short-term physiotherapy goals & time frame] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Long-term physiotherapy goals & time frame] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) SUBJECTIVE: - [Detailed narrative of the patient's self-report of their current status, symptoms, reason for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Patient's activity level, disability, social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Goals and prior response to treatment intervention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Information from family or caregivers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) OBJECTIVE: - [Physical examination details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Observations, tests, and measurements by the therapist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Specific measurements and assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) ASSESSMENT: - [Therapist's professional opinion based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Prioritized problems list] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Progress towards stated goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Factors affecting progress and any need for modification in the plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) PLAN: _(Must be specific, progressive, and functional)_ **- Short-term goals:** [measurable and functional] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) **- Medium/long-term goals:** [contextualised to patient needs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) **- Planned interventions:** [techniques, frequency, progression strategy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) **- Next steps:** [what will be done in the next sessions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) **- Patient education:** [topics explained or to be reinforced] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) **- Referrals:** [if applicable (imaging, specialist, etc.)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Detailed treatment plan including interventions, frequency, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Anticipated goals and expected outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Equipment required and its usage] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Education strategies for the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) TREATMENT PERFORM: - [Details of the specific interventions and exercises performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Patient's response to the treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Summary of the patient's progress during this session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Notable improvements or challenges observed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) NEXT APP: - [What will be worked on in the next session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Specific goals or exercises planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) - [Modifications to the treatment approach] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit section entirely.) (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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank and specify if it involves the LEFT (L) or RIGHT (R) side if mentioned.)