Sports Medicine Review Consultation Notes

REFERRED BY: [Name of referring practitioner] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Referral source, e.g. GP, Physiotherapist, Exercise Physiologist, Chiropractor, Online etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) INJURY / CHIEF COMPLAINT: [Diagnosis or description of injury or illness including side of body (if applicable) and region/joint/body system involved] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) REVIEW APPOINTMENT: [Number corresponding to the current review appointment, e.g. 1 for first review after initial, 2 for second, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) CURRENT HEALTH PRACTITIONERS INVOLVED IN PATIENT'S CARE: - Specialist: [Name and clinic location] (Only include if explicitly mentioned in transcript or context, else state "Nil involved in care".) - General Practitioner: [Name and clinic location] (Only include if explicitly mentioned in transcript or context, else state "Nil involved in care".) - Physiotherapist: [Name and clinic location] (Only include if explicitly mentioned in transcript or context, else state "Nil involved in care".) - Exercise Physiologist: [Name and clinic location] (Only include if explicitly mentioned in transcript or context, else state "Nil involved in care".) - Chiropractor: [Name and clinic location] (Only include if explicitly mentioned in transcript or context, else state "Nil involved in care".) CURRENT SYMPTOMS / PROGRESS: [Updated progress of symptoms or illness] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Associated symptoms and changes with therapies] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Effect on ADLs, occupation, sport/recreation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Changes in psychological wellbeing (improvement/decline/no change)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Outcome of treatments/interventions since last appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) CURRENT THERAPIES / TREATMENTS: [List all treatments using the following format: Month and Year, Name of treatment/intervention, Therapy Type (e.g. Physiotherapy, Injection etc.), Number of sessions/injections, Response to treatment (e.g. no/minimal/partial/good/great improvement), Duration of response (if any)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) INVESTIGATION HISTORY: [Imaging modality and body region imaged, using standard abbreviations (e.g. MRI, CT, US)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Date of imaging or reported timeframe (exact if known, otherwise month/year)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Radiology centre where performed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Radiologist’s conclusion or executive summary] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) EXAMINATION FINDINGS: [Findings from physical or clinical examination] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) DIAGNOSIS: [Summary of clinical findings and provisional diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [List of differential diagnoses in order of likelihood] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) TREATMENT PLAN: [Updated management plan, including tests, treatments or referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 1. Further Investigations: [List each investigation separately: Modality, Region, and Booked Date] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 2. Rehabilitation Protocol: [List each modality separately: e.g. strengthening, neuromuscular, proprioceptive, massage, load management etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 3. Medications: [List any oral or topical medications prescribed for symptom/pain management] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 4. Referrals: [List any referrals made, to whom, and when appointment is scheduled] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 5. Follow-Up Appointments: [List all follow-up appointments booked including timeframe and practitioner] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) 6. Contingency Plan: [Plan at follow-up if current treatment plan does not achieve desired outcome] (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 include 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.)