Injury Details & Sequelae:
On 15 October 2024, the client, [insert name], sustained a concussion following a fall while cycling. Initial symptoms included headache, dizziness, and nausea, with a symptom severity rating of 7/10. The client was assessed at the local emergency department and discharged home with instructions for rest and observation. The client reports a gradual improvement in symptoms over the past two weeks, but continues to experience some difficulties with concentration and fatigue. The client has not yet returned to work.
List of relevant medications currently taken to treat concussion symptoms: (e.g. analgesia, anxiolytics, antidepressants, thiamine) (Include dosage and frequency.)
* Paracetamol 500mg, as needed for headache
* Ibuprofen 200mg, as needed for headache
Risk Assessment:
The client presents with several risk factors that may impact their progress, including a high symptom load, and vocational challenges. The client reports significant difficulty with returning to work and is concerned about their ability to fulfil their job duties. The client also reports some psycho-social issues related to the injury, including feelings of isolation and frustration.
Previous Head Injuries:
The client reports no previous head injuries.
Previous Unexplained Loss of Consciousness / Seizures:
The client reports no history of unexplained loss of consciousness or seizures.
Current Health Concerns:
The client reports no current health concerns or medical conditions.
Mental Health:
The client reports a history of mild anxiety, which has been well-managed with cognitive behavioural therapy. The client reports that their anxiety symptoms have increased since the injury and is seeking support to manage these symptoms.
Psychological Symptoms from Concussion:
The client reports experiencing increased anxiety, irritability, and difficulty with concentration since the concussion. The client reports that these symptoms are more severe than their pre-concussion psychological state.
Alcohol and Drug Information:
The client reports occasional alcohol consumption (1-2 drinks per week) prior to the injury. The client has abstained from alcohol since the injury. The client does not smoke or use recreational drugs. The client consumes 1-2 cups of coffee per day.
Daily Activities:
The client reports some difficulties with personal cares, including showering and dressing, due to fatigue and dizziness. The client is able to perform basic household responsibilities, but requires frequent rest breaks. The client reports that their usual leisure activities, such as cycling and reading, are limited due to symptoms. The client is not currently driving. The client is currently off work. The client lives with their partner. The client reports good support from their partner and family, but is concerned about the impact of their injury on their work.
Injury Details & Sequelae:
[Describe injury details including date of injury, accident details, initial symptom severity, subsequent recollection of events, and initial treatment or testing undertaken. Comment on whether the client has returned to work or school, specifying part-time or full-time if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
List of relevant medications currently taken to treat concussion symptoms: (e.g. analgesia, anxiolytics, antidepressants, thiamine) (Include dosage and frequency.)
[Current medication being taken for concussion symptoms, including dosage and frequency] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points, with each medication on a new line.)
Risk Assessment:
[Comment on any identified risk factors or barriers that may impact the client's progress, such as high symptom load, BIST score, previous TBI, neurological conditions, mental health issues, mood disturbances, vocational challenges, psycho-social issues, or drug/alcohol concerns.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Previous Head Injuries:
[Document any history of previous head injuries.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Previous Unexplained Loss of Consciousness / Seizures:
[Document any history of previous unexplained loss of consciousness or seizures.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Current Health Concerns:
[Document any current health concerns or medical conditions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Mental Health:
[Document current and past mental health conditions, treatments, and ongoing support, including any desire for changes in mental health care due to the current injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Psychological Symptoms from Concussion:
[Document any psychological symptoms experienced since the concussion, including comparison to pre-concussion psychological states.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Alcohol and Drug Information:
[Document information regarding alcohol consumption, smoking/vaping status, recreational drug use, and caffeine intake, noting any changes since the injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Daily Activities:
[Document the patient's ability to perform personal cares and household responsibilities since the injury, including any difficulties encountered.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
[Document the patient's usual leisure activities, hobbies, and work-related activities, noting any changes or limitations since the injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
[Document the patient's driving habits and any continued driving since the injury, including details about commute duration or road conditions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
[Document the patient's work attendance and any discussions or decisions made regarding time off work following the injury.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
[Document details about the patient's living situation, household members, their ages, and any relevant caregiving roles or school attendance for dependents.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
[Document the patient's perception of family and work support.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of 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, 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.)
