Chiropractor
Well balanced video call 1-1
Subjective
Patient reports feeling generally well. Currently in week 3, day 5 of the recovery app. Finding the exercises helpful, especially the spinal mobility drills. Applied advice regarding ergonomic adjustments at work, noticing reduced stiffness. Planning a short holiday next month which may impact exercise consistency. Noted a slight decrease in lower back pain intensity since last visit. No other clinically relevant details.
Discussion and Education
Discussed the importance of maintaining spinal mobility during travel. Educated patient on modified exercises for their upcoming trip. Reviewed progress on current exercise programme and confirmed understanding of proper form.
Changes to be made: Slight increase in duration for current stretching exercises for next two weeks. Introduced a new core strengthening exercise.
Analysis:
To note:
Patient responds well to visual demonstrations of exercises. Prefers early morning appointments. Motivated to adhere to home exercise plan.
Working Diagnosis:
Chronic lower back pain with associated lumbar stiffness.
Plan
Patient to continue daily exercises, focusing on increased stretch duration and new core exercise. Clinician to monitor progress via app and next follow-up. Follow-up recommended in 2 weeks. Follow-up booked for 1 November 2024 at 10:00 AM.
(Use short sentence structuring and wording even if grammatically incomplete for ease of speed reading whilst remaining very explicit and specific with the relevant details from the patient. Never include direct patient quotes in the output).
Subjective
[Describe how the patient has been and state where they are in the app including week and day number] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Describe how the patient has found their exercises] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Describe how the patient has been getting on with any advice given and applying it] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Mention any miscellaneous details such as upcoming trips or other events happening in their life that may be important or useful to remember for relationship and rapport building in future consultations] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Describe any changes in symptoms] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Describe any other clinically relevant details] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
Discussion and Education
[Detail any education provided or discussions had about symptoms, diagnosis, upcoming exercises, and any other clinically relevant education or discussion] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[Detail any changes to be made to the patient's programme for the coming weeks or days] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
Analysis:
To note:
[Record any useful notes to be retained for future visits such as patient preferences, responses to management, lifestyle factors that are helpful to have as a reminder for each visit] (Only add or update if explicitly mentioned or implied in transcript, contextual notes, or clinical note, otherwise retain prior note. Use short sentence structuring and wording even if grammatically incomplete whilst remaining very explicit and specific with the relevant details from the patient.)
Working Diagnosis:
[Copy the working diagnosis or diagnoses from context verbatim if provided] (Only include if explicitly mentioned or implied in contextual notes or clinical note, else omit section entirely. Do not include diagnosis from transcript. Do not invent or infer a diagnosis.)
[Add any new diagnoses if mentioned in transcript] (Only include if explicitly mentioned or implied in transcript, else omit section entirely. Do not include diagnosis from contextual note or clinical note. Do not invent or infer a diagnosis.)
Plan
[Summarise actions from patient and clinician until next visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
[State when follow-up has been recommended and when or if it has been booked] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)