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Physical Medicine and Rehabilitation Specialist Template

Follow-up myoActivation Patient Encounter [Heidi]

A professional Physical Medicine and Rehabilitation Specialist template for healthcare professionals.
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Need a detailed record of your myoActivation treatments? This template helps physical medicine and rehabilitation specialists document patient encounters, including assessments, treatment details, and aftercare instructions. It's designed to capture specific movements, pain levels, and procedural information. With Heidi, this template can be quickly populated from your visit transcript, saving you time and ensuring comprehensive documentation for each patient's progress.

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Follow-up myoActivation Patient Encounter Date: 2024 11 01 "This encounter note reflects a follow-up visit." Change Since Previous Encounter The patient reports a significant reduction in lower back pain, from a 7/10 to a 2/10, since the last treatment session. They also report improved mobility and are now able to bend over to tie their shoes without difficulty, a task that was previously very challenging. The patient states they feel more confident in their ability to perform daily activities. ASSESSMENT Plantar Weight The patient reports that they feel more weight is being distributed on the outside of their left foot, and they are experiencing some discomfort in that area. Postural Symmetry Observation reveals a slight forward head posture and mild asymmetry in the shoulders. There is a slight elevation of the left hip compared to the right. TREATMENT "All myoActivation treatment involves injections of 0.9% normal saline microaliquots precisely targeted to densities within myofascial tissue at palpable painful points." BASE Test Series 1 Extension Arms Raised The patient reported a 3/10 pain in the left trapezius muscle during the test. Range of motion was slightly restricted. After treatment, the pain decreased to 0/10. Extension Arms Down The patient reported no pain during this test. Flexion Arms Down The patient reported no pain during this test. Squat Arms Down The patient reported no pain during this test. Squat Arms Raised The patient reported no pain during this test. Lateral Arch to Patient's Right The patient reported no pain during this test. Lateral Arch to Patient's Left The patient reported no pain during this test. Procedural Treatment 1 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 2 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 2 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 3 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 3 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 4 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 4 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 5 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 5 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 6 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 6 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 7 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 7 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch BASE Test Series 8 Extension Arms Raised - No pain reported. Extension Arms Down - No pain reported. Flexion Arms Down - No pain reported. Squat Arms Down - No pain reported. Squat Arms Raised - No pain reported. Lateral Arch to Patient's Right - No pain reported. Lateral Arch to Patient's Left - No pain reported. Procedural Treatment 8 * Left trapezius muscle, 25 gauge, 1 inch * Right quadratus lumborum, 25 gauge, 1 inch AFTERCARE [Patient's first name] was advised not to undertake exertional activities for the next 5 days. Helpful to change posture every 15-20 minutes. Important not to walk more than 15 minutes at any one time but can engage in short walks multiple times per day. Follow-up appointment scheduled in two weeks to assess progress and adjust treatment plan as needed.
Follow-up myoActivation Patient Encounter Date: [Insert date] (use date format of YYYY MM DD) "This encounter note reflects a follow-up visit." Change Since Previous Encounter [describe changes, improvements, or worsening since the previous treatment session, including patient-reported outcomes, functional improvements, symptom changes, treatment response, and any developments in the patient's condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format using full sentences.) ASSESSMENT Plantar Weight [document patient comments regarding weight distribution on right or left foot, weight distribution on inside or outside of feet, weight distribution on heel or toes, and any patient-reported sensations about weight bearing] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as descriptive text in full sentences.) Postural Symmetry [document clinician observations and comments on abnormal postural findings, asymmetries, alignment issues, postural compensations, and clinical assessment of posture] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as descriptive text in full sentences. Do not include any comments by the patient.) TREATMENT "All myoActivation treatment involves injections of 0.9% normal saline microaliquots precisely targeted to densities within myofascial tissue at palpable painful points." BASE Test Series 1 Extension Arms Raised [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Extension Arms Down [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Flexion Arms Down [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Squat Arms Down [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Squat Arms Raised [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Lateral Arch to Patient's Right [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Lateral Arch to Patient's Left [document clinician's description of pain location, pain intensity, restriction in movement, range of motion limitations, and treatment response for this specific movement test] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Procedural Treatment 1 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 2 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 2 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 3 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 3 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 4 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 4 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 5 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 5 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 6 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 6 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 7 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 7 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) BASE Test Series 8 [list each movement test name, followed by a hyphen, followed by clinician's comment on the result of the movement test, covering pain response, range of motion, restrictions, and functional improvements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. List all individual movement tests using the format described.) Procedural Treatment 8 [list specific tissue or muscle names treated, needle gauge used, needle length used, and any additional procedural details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) AFTERCARE [document patient first name] "was advised not to undertake exertional activities for the next 5 days. Helpful to change posture every 15-20 minutes. Important not to walk more than 15 minutes at any one time but can engage in short walks multiple times per day." [document specific recommendations for follow-up visit including timing and scheduling details] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Whenever a pain level or pain intensity rating is stated by the patient, write this subjective quantification in the format of: a number between 0 to 12, single space, slash mark, single space, the number 10.) (Always refer to the patient by their first name.) (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.)
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Physical Medicine and Rehabilitation Specialist

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Note

Last edited

16/9/2025

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