Chiropractor Initial Consultation

Subjective Presenting Complaint: - [Detailed description of the current presenting complaint: location, quality, severity (VAS/NRS), aggravating and relieving factors, and duration.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Personal Goals (SMART) - Specific: [The exact goal they want to achieve.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Measurable: [How the goal is tracked.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Achievable: [Why the goal is realistic for this patient.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Relevant: [Why the goal is important to the patient's life.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Time-frame: [The desired date or period for achieving the goal.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) When did it start? How has it changed? - [Onset, including potential mechanism of injury (MOI) or gradual onset details.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Evolution of symptoms since onset (improving, worsening, stable, shifting).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical History / Contraindications - [Relevant past medical history, current medications, previous treatment, and any known drug allergies or contraindications.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Red Flag Questions: - [Summary of responses to red flag screening questions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Personal Notes / Other - [Any other information they mention, such as personal life, work activities, personality details, or context relevant to their condition.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective Diagnosis Exam: - Blood pressure: [Record the patient's blood pressure reading.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Abdominal exam for LBP patients: [Record findings from the abdominal exam (if performed).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Observation: - [Describe key observations: posture, gait, swelling, visible asymmetry, or guarding.] (Include any details about the visible appearance of the patient. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ROM and Function: Active / functional: - Flexion: [Active ROM findings for flexion, including quality and end-feel.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Extension: [Active ROM findings for extension, including quality and end-feel.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lateral Flexion (L/R): [Active ROM findings for lateral flexion left and right, including quality and end-feel.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Rotation (L/R): [Active ROM findings for rotation left and right, including quality and end-feel.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Other Specific ROM: [Specific active ranges of motion or functional tests mentioned by the patient.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Passive: - [Passive range of motion (PROM) findings, including end-feel and restriction pattern.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Palpation: - [Detailed findings from palpation, including muscle tone, temperature, tender points, joint play, or oedema.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neuro/Orthopaedic Tests: Positive - [List specific positive neuro/orthopaedic tests and the resulting findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What hurts or feels tight/tender and when, which side and to what extent?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) NAD - [List specific neuro/orthopaedic tests that were No Abnormality Detected (NAD).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What doesn't hurt or feels fine.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Action Manual / Exercise Therapy: - [Detailed list of treatment provided during the first session: techniques, joints, duration, sets/reps of exercise therapy.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What hands-on manual therapy was provided during the session? Did the practitioner seek consent? Was it given?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Include further details about the hands-on manual therapy given such as why it was offered or not offered, information about the style of manual therapy or reasoning behind offering it, what to expect, etc. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Advice and Guidance: - [Specific advice and guidance given during the session.] (What advice, guidance, or education was given during the session? Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Education and Reassurance: - [Summary of reassurance provided regarding findings and safety of movement.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Further details of patient education and reassurance provided, including expected post-treatment reaction.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan Summarised SMART goal: - [Brief, memorable summary of the patient's main treatment goal.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Their Homework: - [New exercises/activities prescribed, including dosage (sets/reps/frequency).] (Use a separate bullet point for each task. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) How to incorporate play? - [Specific advice on how the patient can safely reintroduce an aspect of play or enjoyment into their activity/lifestyle using fun or novel movements and games.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) For next appointment? - [Specific plan for the next session: re-tests, treatment focus, and progression strategy.] (Bullet point a list of what the practitioner should do at the next appointment. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Payment and Recall made? - Payment Made? [Record status of payment made, and how much.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - MSK-HQ reminder / recall made? [Record if the MSK-HQ reminder or future appointment recall was scheduled/set up.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary Summary / description. Clinical Reasoning for Diagnosis Working Diagnosis: - [Your primary working diagnosis.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Differential Diagnoses: - [Alternative possible diagnoses considered.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Prognosis: - [Estimated prognosis, including expected duration and anticipated level of functional recovery.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (AI Instructions: 1. Source of Truth & Confidentiality: Never generate or invent patient details, assessment findings, or diagnoses. Use only the content explicitly mentioned in the dictated transcript, contextual notes or clinical note as a reference for the information to include in your note. 2. Clinical Tone: Maintain a concise, professional, and clinical style throughout the note, mirroring the language a UK chiropractor would use for Initial Consultation notes. 3. Placeholder Omission: If any information related to a placeholder (text inside [ ]) 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 bullet point blank. 4. Formatting: Transcribe the dictated notes into the structured format above, strictly adhering to the headings and list format. Do not include these bracketed AI instructions or any instructional text in the final output.)