**Brief Summary:**
- Patient presents with ongoing right shoulder pain and limited range of motion following a fall two weeks ago. Currently undergoing physiotherapy to improve mobility and reduce pain.
- Patient reports slight improvement in pain levels since the last session, but range of motion remains limited.
- Continue with current treatment plan, reassess progress in two weeks.
"Clinical entry generated with Heidi AI medical notetaking software. Patient verbal consent obtained for recording at commencement of session or in prior session. Edits/corrections made manually after automatic clinical notes generation."
**Update on Patient Symptoms / Recent History:**
- Patient reports a sharp increase in pain after attempting to lift a heavy object yesterday. Pain is now radiating down the arm.
- Patient has been resting the arm and using ice as instructed.
**Rehab Since Last Review:**
- Tolerating exercises well, performing them daily.
- Exercises performed daily as instructed.
- Compliant with previous instructions.
- Patient expressed concern about the recent increase in pain.
- Patient reported a slight improvement in pain levels before the recent flare-up.
- Patient feels the exercises were helping to improve range of motion before the recent increase in pain.
**Patient Goals / Expectations:**
- Patient aims to regain full range of motion and return to pre-injury activity levels.
**Relevant Social History:**
- Patient is a construction worker and needs to return to work as soon as possible.
**Physical Examination:**
- Range of motion: Shoulder flexion limited to 90 degrees, abduction limited to 80 degrees.
- Strength: Weakness noted in shoulder abduction (3/5).
- Palpation: Tenderness over the supraspinatus tendon.
- * * * * * Neer's test positive.
**Ongoing / Updated Diagnostic Impression:**
- Suspected rotator cuff tendinopathy with possible impingement.
**Treatment / Intervention:**
- Manual therapy to the shoulder joint.
- Soft tissue massage to the surrounding muscles.
- Instruction in pain management techniques.
**Reassessment Findings (Post-Treatment):**
- Patient reports a slight reduction in pain after treatment.
- * * * * * Neer's test remains positive.
**Advice / Exercises:**
- Continue with home exercises, including pendulum swings and gentle range of motion exercises.
- Avoid activities that exacerbate pain.
- Apply ice for 15-20 minutes, 3-4 times per day.
**Plan:**
- Schedule a follow-up appointment in two weeks.
- Review progress and adjust treatment plan as needed.
- Discuss the possibility of further imaging if symptoms do not improve.
**Additional Notes:**
- Patient was advised to contact the clinic if pain worsens significantly.
**Dictated Letter:**
"transcribe the following verbatim"
Patient is advised to rest and avoid aggravating activities. Further review in two weeks.
"end of dictation"
(Avoid using plain patient language descriptions given to patient in the clinical notes; instead replace with medical terminology where a clear replacement is available.)
**Brief Summary:**
- [Maximum 40 word summary of condition/s and current interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Create a new dot point for each piece of information.)
- [Brief comments on improvement, decline, or unchanged status since last session] (Only include if explicitly mentioned…)
- [Brief summary of plan] (Only include if explicitly mentioned…)
"Clinical entry generated with Heidi AI medical notetaking software. Patient verbal consent obtained for recording at commencement of session or in prior session. Edits/corrections made manually after automatic clinical notes generation."
[Where possible list each subheading separately for each body part/issue if there is more than one injury/complaint.]
**Update on Patient Symptoms / Recent History:**
- [New symptoms or changes in existing symptoms] (Only include if explicitly mentioned…)
- [Recent events or activities impacting condition] (Only include if explicitly mentioned…)
**Rehab Since Last Review:**
- [Tolerance to previously prescribed rehab and exercises] (Only include if explicitly mentioned…)
- [Frequency of previously prescribed rehab and exercises] (Only include if explicitly mentioned…)
- [Compliance with previous instructions] (Only include if explicitly mentioned…)
- [Problems or concerns discussed] (Only include if explicitly mentioned…)
- [Improvements discussed] (Only include if explicitly mentioned…)
- [Patient’s feedback on whether rehab/exercises helped] (Only include if explicitly mentioned…)
**Patient Goals / Expectations:**
- [Patient’s current goals and expectations for physiotherapy] (Only include if explicitly mentioned…)
**Relevant Social History:**
- [Relevant social history impacting treatment, e.g., changes in living situation, work, family dynamics] (Only include if explicitly mentioned…)
**Physical Examination:**
- [Findings from physical examination, including range of motion, strength, and other assessments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Include all physical examination details mentioned, including negative findings.)
- (If instructions are verbalised to mark a finding or test as a "key assessment," place five asterisks at the start of the line reporting that test. Repeat when listing in the reassessment section.)
**Ongoing / Updated Diagnostic Impression:**
- [New diagnostic findings or updates to existing diagnosis] (Only include if explicitly mentioned…)
**Treatment / Intervention:**
- [Treatment or interventions provided during the session] (Only include if explicitly mentioned…)
**Reassessment Findings (Post-Treatment):**
- [Patient’s response to treatment/interventions provided] (Only include if explicitly mentioned…)
**Advice / Exercises:**
- [Advice given to patient, including home exercises or activity modifications] (Only include if explicitly mentioned…)
**Plan:**
- [Plan for future treatment sessions, including changes to treatment approach or goals] (Only include if explicitly mentioned…)
**Additional Notes:**
- [Other clinical comments in transcript not fitting categories above, including instructions verbalised as being for 'Heidi' or asked to be included in the clinical note] (Only include if explicitly mentioned…)
**Dictated Letter:**
"transcribe the following verbatim"
[Verbatim letter content] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
"end of dictation"
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, exam findings, interventions, diagnostic impressions, advice, or plans—use only the transcript, contextual notes or clinical note as reference. If any information has not been explicitly mentioned, do not state that it was not mentioned; simply omit it. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
