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Wolfson assessment clinic appointment between Dr. Sarah Jones, Speech and Language Therapist and Mrs. Emily Carter on 01/11/2024 at 10:00 for 60 minutes. Aim of this assessment is to determine if Mrs. Carter would still like rehabilitation and whether the Wolfson would provide the most suitable intervention.
Mrs. Carter was referred by Dr. David Smith on 15/10/2024. The referral letter is on file and will not be duplicated here.
**Name:** Emily Carter
**Tel. No:** 07700 900123
**Email:** emily.carter@email.com
**DOB:** 12/03/1985
**MRN:** 1234567
**NOK name:** John Carter
**NOK Tel. No:** 07700 900456
**NOK email:** john.carter@email.com
**Onset of symptoms**
Mrs. Carter reports that her symptoms began approximately 6 months ago, following a viral illness. She initially experienced difficulties with speech and swallowing, which gradually worsened. She also reports experiencing fatigue and cognitive difficulties.
**1. Current list of symptoms**
* **Speech:** Mrs. Carter reports significant speech difficulties, including slurring, stuttering, and difficulty finding words. She describes her speech as being worse when she is tired or stressed. She currently uses communication strategies such as writing things down and using gestures. These strategies are moderately effective.
* **Swallowing:** Mrs. Carter reports difficulty swallowing, particularly with solids. She has modified her diet to include softer foods and liquids. She reports occasional coughing when eating. She is currently using thickened fluids. These strategies are moderately effective.
* **Fatigue:** Mrs. Carter reports significant fatigue, which impacts her ability to participate in daily activities. She rests frequently throughout the day.
* **Cognitive difficulties:** Mrs. Carter reports difficulties with memory, attention, and executive function. She uses a diary and reminders to help manage her cognitive difficulties.
Mrs. Carter describes a typical day as involving waking up, having breakfast (modified diet), resting, completing some light housework, resting again, and then preparing dinner. She requires assistance from her husband with some tasks.
**2. Patient's understanding of FND**
Mrs. Carter states, "I understand that FND is a condition where my brain isn't communicating properly with my body, causing my speech and swallowing problems."
**3. Agreement with diagnosis of FND**
YES: [x]
Mrs. Carter states, "I agree with the diagnosis because it explains the symptoms I'm experiencing, and I haven't found any other explanation for my symptoms."
**4. Seeking a second opinion**
NO: [x]
Mrs. Carter states, "I am happy with the diagnosis and the care I am receiving."
**5. Current list of diagnoses**
* Functional Neurological Disorder (FND) - diagnosed 2 months ago
**6. Previous treatments or interventions**
Mrs. Carter has received speech therapy and dietary advice from a speech and language therapist. She has also seen a neurologist and a gastroenterologist.
**7. Rehab Goals**
* Improve speech intelligibility.
* Improve swallowing safety and efficiency.
* Increase independence with daily activities.
**8. Happy with online assessment as a precursor to taking part in rehab?
**YES: [x]
Mrs. Carter is happy to participate in online sessions.
**9. Suitable quiet space for online sessions**
YES: [x]
**10. Current capacity to engage in therapy sessions**
Mrs. Carter is willing to engage in therapy sessions for 60 minutes, 3 times a week.
**11. How would patient access assistance during an appointment if needed?**
Mrs. Carter stated that her husband will be present during the sessions and can assist her if needed. There are no safeguarding issues.
**12. Presence of someone in the home if necessary?**
Mrs. Carter's husband will be present during the sessions.
**13. Falls**
Mrs. Carter has not experienced any falls.
**14. Standing**
Mrs. Carter is able to stand independently for short periods of time.
**15. Functional seizures**
Mrs. Carter has not experienced any functional seizures.
**16. Dystonia**
Mrs. Carter has not experienced any dystonia.
**17. Mood and risk**
Mrs. Carter reports feeling anxious and frustrated due to her symptoms. She denies any thoughts of self-harm. Protective factors include support from her husband and family.
**18. History of trauma**
Mrs. Carter denies any history of trauma.
**19. Use of alcohol and recreational drugs**
Mrs. Carter does not consume alcohol or recreational drugs.
**20. Preferred mode of intervention**
Mrs. Carter prefers online speech therapy sessions.
**21. NOK details and consent for them to be contacted in an emergency**
John Carter, husband, 07700 900456. Consent given to contact in an emergency.
**22. Current life stressors**
Mrs. Carter is experiencing stress related to her symptoms and the impact they have on her daily life.
**23. Current medications**
* Sertraline 50mg daily
**Outcome**
Mrs. Carter is suitable for the Wolfson rehabilitation program. The next step is to schedule her for an initial speech therapy assessment and develop a treatment plan.
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Wolfson assessment clinic appointment between [clinical name and designation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) and [patient name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) on [today's date] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) at [current time] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) for [duration of meeting] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.). Aim of this assessment is to determine if [patient name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) would still like rehabilitation and whether the Wolfson would provide the most suitable intervention.
[Patient name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) was referred by [consultant name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) on [date of referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.). The referral letter is on file and will not be duplicated here.
**Name:** [patient full name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Tel. No:** [phone number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Email:** [patient email address] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**DOB:** [patient date of birth in DD/MM/YY format] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**MRN:** [patient hospital number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**NOK name:** [next of kin name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**NOK Tel. No:** [next of kin phone number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**NOK email:** [next of kin email address] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Onset of symptoms**
[provide a summary of patient’s onset of symptoms as provided in the transcription or the context notes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[include medical history as explained by patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(write in full sentences and paragraphs)
(include verbatim language from patient as appropriate, if explicitly present)
**1. Current list of symptoms**
[create subheadings of each symptom mentioned in the transcript and context. List out each symptom, describe onset, variability, current strategies and their effectiveness. Include psychosocial factors like housing, care needs, assistance, legal cases, family, work.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(summarise a current typical day as described by patient including levels of activity, daily tasks, assistance required) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**2. Patient's understanding of FND**
[summarise the patient’s explanation of FND] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(use verbatim quote from patient where appropriate, if explicitly present)
**3. Agreement with diagnosis of FND**
YES: [tick if agrees]
NO: [tick if does not agree]
(summarise patient’s explanation why) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**4. Seeking a second opinion**
YES: [tick if seeking]
NO: [tick if not seeking]
(summarise patient explanation why) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**5. Current list of diagnoses**
[create a list of diagnoses with date of onset/diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**6. Previous treatments or interventions**
[summarise what treatments or interventions patient has experienced] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**7. Rehab Goals**
[list rehab goals as produced by patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**8. Happy with online assessment as a precursor to taking part in rehab?**
YES: [tick if happy]
NO: [tick if not happy]
(summarise discussion) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**9. Suitable quiet space for online sessions**
YES: [tick if available]
NO: [tick if not available]
**10. Current capacity to engage in therapy sessions**
[summarise discussion about ability to take part in sessions of 60–90 minutes 3–4 times a week] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**11. How would patient access assistance during an appointment if needed?**
[summarise discussion about accessing assistance, risks or safeguarding issues, outline any plan made] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**12. Presence of someone in the home if necessary?**
[summarise discussion and plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**13. Falls**
[detailed history of falls, most recent, frequency, injuries, effect on behaviour, risks, safeguards] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**14. Standing**
[detailed outline of standing ability, duration, assistance required, balance, sensations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**15. Functional seizures**
[detailed outline of seizures, onset, triggers, events, duration, management, response, risks in virtual setting] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**16. Dystonia**
[detailed outline of fixed limbs, sensations, changes over time, tolerance, colour/temp changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**17. Mood and risk**
[detailed summary of mood, anxiety, mental health, self-harm, risks, protective factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**18. History of trauma**
[summarise trauma history, manifestations, therapy offered and outcomes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**19. Use of alcohol and recreational drugs**
[summarise type, amount, frequency, impact on mood/symptoms, risks and safeguards] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**20. Preferred mode of intervention**
[summarise discussion of services and stated preference with reasoning] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**21. NOK details and consent for them to be contacted in an emergency**
[summarise discussion and include NOK details and consent] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**22. Current life stressors**
[summarise life stressors impacting rehab] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**23. Current medications**
[list medications with dose/frequency and explanation by patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
**Outcome**
[summarise discussion of outcome, plan and next steps] (Only include if explicitly mentioned in transcript, context or clinical note, 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. If any information related to a placeholder has not been explicitly mentioned, do not state that it was not mentioned; just leave the placeholder or section out entirely.)
