Subjective:
- [Description of current symptoms, including onset, duration, intensity, and character of pain or discomfort, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Detailed history of the presenting complaint(s), noting any specific movements, activities, circumstances that aggravate or alleviate symptoms, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Review of systems to identify any related or contributing symptoms outside the primary complaint (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Past medical history, including previous injuries, surgeries, chronic conditions, any relevant family medical history, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Lifestyle and environmental factors, including occupational hazards, recreational activities, stress levels, diet, exercise habits, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Current medications and supplements, including any non-pharmacological treatments being used (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Social history, considering factors such as support systems, living conditions, and mental health (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Allergies or adverse reactions to medications or treatments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Assessment/ Findings:
- [Vitals: Blood Pressure, Heart Rate, Respiratory Rate, Temperature (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Physical examination findings, focusing on structural assessment, palpation of musculoskeletal system for areas of tension, misalignment, or restricted movement, evaluation of posture, mobility, and gait (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Neurological examination, if relevant, including reflexes, sensory testing, and motor strength (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any diagnostic tests ordered or reviewed, such as X-rays, MRIs, or lab tests pertinent to the osteopathic evaluation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Working Diagnosis:
- [Osteopathic diagnosis or assessment of the patient's condition, integrating findings from the subjective and objective evaluations (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Identification of key areas for osteopathic treatment, including somatic dysfunctions and their potential impact on overall health (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Plan:
- [Detailed treatment plan, outlining the osteopathic manipulative treatment (OMT) techniques to be employed (e.g., soft tissue, myofascial release, high-velocity low-amplitude thrusts) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Expected frequency and duration of treatment sessions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Short-term and long-term goals of treatment, including specific outcomes such as pain relief, improved mobility, and enhanced overall well-being (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Advice on lifestyle modifications, exercises, or ergonomic changes to support treatment outcomes (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Plans for any additional diagnostics or referrals to other healthcare professionals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Treatment/ Treatment response:
- [Details of OMT techniques and any other therapeutic interventions applied during the session, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Immediate response to treatment and any changes in symptoms or function observed, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Additional Notes: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Educational information provided to the patient on managing symptoms, preventing injury, or improving health and wellness (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Specific instructions for home care, exercises, or follow-up activities (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any patient concerns or preferences discussed during the visit (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, 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, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)