Concussion Recovery Progress Note

Reason for Visit: - [Summary of patient's main reason(s) for visit and specific symptoms or concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as sentence.) Visual History: - [Description of any current visual complaints such as blurriness, difficulty reading, headaches during visual tasks, eye strain, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as sentence.) - [Details regarding the onset, duration, and progression of current visual symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) - [History of previous eye examinations, use of glasses or contact lenses, and their effectiveness] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Medical History: - [Chronic medical conditions relevant to eye health, such as diabetes, hypertension, thyroid disease, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Current medications, including prescribed, over-the-counter, and supplements] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Known allergies, especially to medications or eye drops] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Progress Since Last Encounter: - [Reported changes or symptoms since the last visit, such as improvement, worsening, or no change] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Lifestyle Assessment: - [Occupational and recreational activities that require visual focus or pose eye strain risk] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) - [Use of digital screens or other visual risk factors] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as sentence.) - [Environmental exposures such as UV light, wind, chemicals, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as sentence.) Today's Therapy Session and Results of Binocular Vision and Eye Movement Programs: - [Tolerance of the therapy session, including symptoms such as headache, dizziness, double or blurred vision] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.) - [Performance during therapy, such as improvement, stability, difficulty, or inability to perform] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.) Other Relevant Issues: - [Comments from other providers, changes to medications, new injuries or symptoms since last visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Assessment: - [Diagnosis or diagnoses based on examination and clinical findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Any identified risk factors for eye diseases] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Management Plan: - [Recommendations for corrective lenses (e.g., prescription for glasses or contact lenses)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Rx eye medications or treatments provided during the visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Referrals made, such as to ophthalmologists or other specialists] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Instructions for follow-up care, including timeline and criteria for early return if symptoms worsen] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.) - [Date or timeframe scheduled for next review or appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as sentence.) Patient Education: - [Advice given on maintaining visual hygiene, including screen breaks, protective eyewear, and general care] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) - [Instructions provided for proper care and use of glasses or contact lenses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Information provided on expected prognosis or signs to monitor for] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Any Additional Recommendations: - [Lifestyle adjustments or ergonomic tips given to reduce visual strain] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) - [Preventive strategies for preserving long-term eye health] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) (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 included 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.)