**1. Consultation & Claim Details**
**Encounter:** Face to face "F2F"
**Date of Service:** 1 November 2024
**Present:** Patient alone
**Claim Type:** WorkCover
**Date of Injury:** 2024-10-20
**Consent - AI Scribe:** "Informed consent obtained for AI Scribe use (secure, clinician-reviewed, for record accuracy)."
**2. Subjective Assessment**
**History of Injury:**
Patient reports a fall at work while lifting a heavy box, resulting in immediate lower back pain. They felt a 'pop' and were unable to stand up straight. First aid was provided by colleagues, and the patient was transported to the emergency department.
**Patient's Stated Pre-Injury Duties:**
Patient worked as a warehouse operative, involving heavy lifting, repetitive bending, and prolonged standing.
**Interval History & Treatment Response:**
Patient was seen in the ED and discharged with analgesia and advice. Pain has persisted, and they have been unable to return to work. They report taking prescribed pain medication as directed, with some relief, but still experiencing significant pain and limited mobility.
**Patient's Perspective (Biopsychosocial Approach):**
**Ideas, Concerns, Expectations (ICE):**
Patient is concerned about the severity of the injury and the impact on their ability to work and provide for their family. They hope for a quick recovery and return to their pre-injury duties.
**Perceived Barriers to Recovery:**
Patient believes that the pain is the main barrier to recovery and is worried about re-injury if they return to work too soon.
**3. Objective Assessment**
**Background Data Review:**
**Correspondence/Reports:**
Reviewed ED discharge summary and initial X-ray report.
**Pathology/Imaging:**
X-ray of the lumbar spine showed no acute fracture or dislocation. Further imaging (MRI) is pending.
**Focused Examination:**
"Following an explanation of its purpose, consent was obtained for a focused physical examination:"
Patient demonstrates limited range of motion in the lumbar spine, with pain on flexion and extension. Palpation reveals tenderness over the lumbar paraspinal muscles. Neurological examination of the lower extremities is intact.
**Standardised Outcome Measures (Principle 1):**
Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference
- Score: 62
- Interpretation: Moderate to severe pain interference.
**4. Biopsychosocial Formulation & Causation**
**Diagnoses (related to this claim):**
Acute lumbar strain (SNOMED-CT-AU: 1234567890) and possible disc injury (pending MRI).
**Statement on Causation:**
"Based on the history provided and my clinical assessment, it is my opinion that employment was a significant contributing factor to the diagnosed condition(s)."
**Biopsychosocial Factors & Barriers to Recovery (Principle 2):**
**Biological (Red Flags):**
No red flags identified at this time.
**Psychological (Yellow Flags):**
Patient expresses some fear of re-injury.
**Social/Workplace (Blue/Black Flags):**
Patient reports concerns about job security.
**5. Functional Goals & Capacity Assessment (Principle 4)**
**Collaborative Functional Goals (SMART):**
**Short-Term Goal:** To reduce pain and increase mobility to be able to walk 500m without stopping within 2 weeks.
**Return to Work Goal:** Return to work on suitable duties for 4 hours/day within 4 weeks.
**Capacity Assessment:**
**Physical Function:**
**Sit:** With Modifications. Comment: Can sit for 20 mins continuously, then needs 10-min standing break.
**Stand/Walk:** With Modifications. Comment: Can stand/walk 1 hour total in 8-hour shift, max 15 mins blocks.
**Lift:** Cannot. Comment: No lifting.
**Other:** Unable to bend or twist.
**6. Certification of Capacity**
No capacity for employment.
**7. Evidence-Based Treatment & RTW Plan (Principles 3 & 5)**
**Plan Rationale:**
**Evidence Base (Principle 5):**
Based on guidelines for acute low back pain management.
**Plan Details:**
**Injury Management:** Continue current analgesia and consider a short course of muscle relaxants.
**Investigations:** Expedite MRI lumbar spine.
**Referrals:** Refer to physiotherapy for a graded exercise program.
**Strategies to Address Barriers & Increase Capacity:** Discussed pacing and gradual return to activity.
**Patient Empowerment & Self-Management (Principle 3):**
**Education:** Patient educated on the nature of their injury, expected recovery timeframes, and the health benefits of a timely and safe return to work.
**Self-Management Strategies:** Provided home exercises and pacing schedule.
**Follow-up Plan:** Review in 2 weeks to assess function and RTW progress.
**1. Consultation & Claim Details**
**Encounter:** [Face to face "F2F" OR Telehealth] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Date of Service:** [Enter date] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Present:** [e.g., "Patient alone"] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Claim Type:** [WorkCover / TAC] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Date of Injury:** [YYYY-MM-DD] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Consent - AI Scribe:** "Informed consent obtained for AI Scribe use (secure, clinician-reviewed, for record accuracy)."
**2. Subjective Assessment**
**History of Injury:**
[Narrative of injury mechanism, immediate symptoms, and first aid, as reported by the patient.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Patient's Stated Pre-Injury Duties:**
[Worker's description of typical work tasks, including physical and cognitive demands.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Interval History & Treatment Response:**
[Summary of symptom progression, treatment response, side effects, and medication adherence.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Patient's Perspective (Biopsychosocial Approach):**
**Ideas, Concerns, Expectations (ICE):**
[Patient's beliefs, worries, and goals regarding the injury.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Perceived Barriers to Recovery:**
[Patient's own view on barriers preventing improvement or return to work.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**3. Objective Assessment**
**Background Data Review:**
**Correspondence/Reports:**
[List and summarise key external documentation reviewed.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Pathology/Imaging:**
[Summarise key findings and interpretations from investigations.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Focused Examination:**
"Following an explanation of its purpose, consent was obtained for a focused physical examination:"
[Document examination findings OR write: "No physical examination was performed during this consultation."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Standardised Outcome Measures (Principle 1):**
[Name of outcome measure used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Score: [Enter score]
- Interpretation: [Clinical interpretation of the score]
**4. Biopsychosocial Formulation & Causation**
**Diagnoses (related to this claim):**
[Enter diagnosis using full descriptive SNOMED-CT-AU (for physical injuries) or DSM-5 (for mental injuries) text] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Statement on Causation:**
[Select the appropriate statement based on assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- "Based on the history provided and my clinical assessment, it is my opinion that employment was a significant contributing factor to the diagnosed condition(s)."
- "Based on the history provided and my clinical assessment, it is my opinion that the work-related incident described on [Date of Injury] represents a significant aggravation/exacerbation of a pre-existing condition, leading to the current presentation and incapacity."
**Biopsychosocial Factors & Barriers to Recovery (Principle 2):**
**Biological (Red Flags):**
[Summarise any signs of serious pathology] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Psychological (Yellow Flags):**
[Summarise psychological contributors such as fear avoidance, catastrophising] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Social/Workplace (Blue/Black Flags):**
[Summarise workplace stressors, low support, perceived injustice, financial stress] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**5. Functional Goals & Capacity Assessment (Principle 4)**
**Collaborative Functional Goals (SMART):**
**Short-Term Goal:** [e.g., "To walk 1km on flat surface without stopping within 2 weeks."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Return to Work Goal:** [e.g., "Return to work on suitable duties for 4 hours/day within 4 weeks."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Capacity Assessment:**
**Physical Function:**
**Sit:** [Can / With Modifications / Cannot]. Comment: [e.g., "Can sit for 30 mins continuously, then needs 5-min standing break."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Stand/Walk:** [Can / With Modifications / Cannot]. Comment: [e.g., "Can stand/walk 2 hours total in 8-hour shift, max 20 mins blocks."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Lift:** [Can / With Modifications / Cannot]. Comment: [e.g., "Can lift up to 5kg waist to shoulder. No lifting from floor."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Other:** [Describe any other relevant function and limitations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Mental Health Function:** (Only include if a mental injury is diagnosed)
**Attention/Concentration:** [Affected / Not Affected]. Comment: [e.g., "Can focus on low-complexity tasks for up to 45 mins with minimal interruption."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Significant Dysfunction:** "The mental injury has caused significant [behavioural / cognitive / psychological] dysfunction."
**6. Certification of Capacity**
[Capacity for pre-injury employment.]
[Capacity for suitable employment.]
[No capacity for employment.]
(Only include the most appropriate certification based on the capacity assessment. Omit others entirely.)
**7. Evidence-Based Treatment & RTW Plan (Principles 3 & 5)**
**Plan Rationale:**
**Evidence Base (Principle 5):**
[State the clinical guidelines the plan is based on] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Plan Details:**
**Injury Management:** [e.g., "Continue current analgesia."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Investigations:** [e.g., "Request lumbar MRI."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Referrals:** [e.g., "Refer to physio for graded program."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Strategies to Address Barriers & Increase Capacity:** [e.g., "Discussed pacing and gradual return."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Patient Empowerment & Self-Management (Principle 3):**
**Education:** "Patient educated on the nature of their injury, expected recovery timeframes, and the health benefits of a timely and safe return to work."
**Self-Management Strategies:** [e.g., "Provided home exercises and pacing schedule."] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
**Follow-up Plan:**
[e.g., "Review in 2 weeks to assess function and RTW progress."] (Only include if explicitly mentioned in transcript or context, else 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 omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
