Yates Physio Initial

SE:// Consent to Heidi Ai: [Does the client consent to use of Ai scribe] (Only include if the client was asked specifically, write answer as yes or no. If client was not asked, indicate as such.) Main Problem: [Indicate reason for client attending consult] (Very brief description of their main concern.) Bodychart: Red flags (NIF TIV) [Indicate red flags including: Neurological, Inflammatory, Fracture, Trauma, Illness/Infection, Vascular, Cancer] (Only include if explicitly mentioned in the transcript, contextual notes or clinical notes; otherwise leave as \"Nil\".) Smoking status [Do they smoke, how much, how often. If they stopped smoking, indicate how long ago.] (Only include if explicitly mentioned; otherwise leave as \"Nil\".) Altered sensation [Do they mention changes in sensation? Hot, cold, paraesthesia, anaesthesia etc.] (Only include if explicitly mentioned; otherwise leave as \"Nil\".) Behaviour: Pain at rest – [Severity (x/10), descriptor (sharp/ache/burning etc), depth, where (localised/diffuse)] (Use clinical notes, transcript, and context notes to inform. Include location.) Pain on aggravation – [Severity (x/10), descriptor (sharp/ache/burning etc), depth, where (localised/diffuse)] Other Sx – [Mention other symptoms associated with main problem or denial thereof.] (Only include if explicitly mentioned.) (If there are multiple pain areas, include all. Indicate relationships if client indicates such.) Agg: • [Symptom trigger - duration] (Dot point format, e.g., • Walking – 10 minutes) Ease: • [Symptom reliever - duration] (Dot point format, e.g., • Sitting – 10 minutes) Non-agg: • [Activities that do not aggravate] (Include only if explicitly mentioned. Dot point format.) Non-ease: • [Activities that do not ease] (Include only if explicitly mentioned. Dot point format.) Irritability: [low/moderate/high] (Use aggravation/ease profile and severity.) 24 hr cycle: [Describe symptom variation across day] (Only include if client indicates this.) Sleeping: [Is sleep affected, how and why] (Include if due to main problem or as a separate issue.) HPC: [Describe history of presenting complaint: onset, progression, cause, improvement/deterioration/stability.] (Use transcript, context notes and clinical notes.) Past Hx: [Mention previous bouts of same complaint, frequency, duration, management.] PMHx (how they got better): [Mention any past medical history. Include how each condition is managed. Most to least recent.] (Only include if explicitly mentioned.) SHx: Occupation: [Client’s occupation.] General health: [Overall health status, including physical activity, sleep, stress, diet, pregnancy, alcohol.] (Brief, only include if explicitly mentioned.) Home: • [Living situation, family members] • [Formal supports: NDIS, HCP, services, equipment] • [Informal supports: Friends, family, colleagues] (Dot point format. Include what support, by whom, how often.) Medications: • [Medication – dose, frequency, reason] (Dot point format. Only include if mentioned.) Clinical flags: • [Biopsychosocial factors – orange/yellow/blue/black flags only] (Dot point format. No red flags.) Investigations: • [Type, location, date, findings] (Dot point format. Only include if mentioned.) What do you think is wrong?: [Client’s interpretation of their issue.] Expectations: [Client’s expectations of physiotherapy.] Long term solution?: [Whether client seeks long-term solution. Only include if mentioned.] Goals: • [SMART goal 1] • [SMART goal 2] • [SMART goal 3] (Dot point format. If not stated, infer from functional limitations.) --- OE:// Outcome Measure [Record ROM tests performed] [AROM/PROM by joint – each test and joint on a new line.] [Resisted static contraction – joint/muscle tested, side, reproduced symptoms (VAS/sensation)] (Each on a separate line.) [Assisted joint movements – PAIVMs/PPIVMs type, direction, grade (1–4+)] (Only if mentioned.) [Neurodynamic – test type, side, reproduction/sensitisation findings.] (Each side on its own line.) [Neurological – upper/lower] • Sensation – [Dermatome – finding] • Strength – [Myotome – finding] • Reflex – [Reflex – finding] • UMN – [Test – result] (Each test on its own line. Indicate \"NAD\" or ✓ if affected.) (Only include findings explicitly mentioned. Insert line breaks between test categories.) --- Provisional Dx:// [Provisional diagnosis] • [Differential diagnosis 1] • [Differential diagnosis 2] • [Differential diagnosis 3] (Dot point format under provisional.) --- Rx:// [Describe treatments provided during session.] • [Manual therapy technique – area – grade/duration] • [Exercise – type – reps/sets/frequency] • [Ergonomics – advice/equipment prescribed] • [Dry needling – consent, infection control, response] • [Education/advice – key points] [Include effect of intervention:] • Intervention // **improved** • Intervention // **no change** (Only include if explicitly mentioned.) --- Plan:// [Next steps – follow-up plan] [Next visit timing – format e.g. \"2/7\"] • [Re-Ax needs] • [Pending assessments] • [Intervention trial for next session] • [Referrals, reports required] (Only include if explicitly mentioned. Keep concise.)