Chiropractor Group Consultation Note
Date: 1 November 2024
Subjective:
Sarah:
Week 4, day 3 in app. Back discomfort improved. Continuing with exercises.
John:
Week 5, day 1 in app. Neck stiffness slightly better. Finding exercises challenging. Attending nephew's wedding next week.
Maria:
Week 3, day 5 in app. Lower back pain fluctuates. Applying advice on posture. No significant changes in symptoms.
Analysis:
Sarah:
Diagnosis: Chronic Low Back Pain
To Note: Goal to increase core strength. Responds well to manual therapy. Pilates enthusiast.
John:
Diagnosis: Cervicalgia
To Note: History of desk work. Goal to improve neck mobility. Prefers visual aids for exercises.
Maria:
Diagnosis: Sacroiliac Joint Dysfunction
To Note: Struggles with consistency. Benefits from regular check-ins. Has two young children.
Discussion and Education:
Discussed importance of proper form during exercises to prevent compensatory movements. Reviewed progression of core stability exercises for weeks 4-6. Emphasised consistency in home exercises, even on busy days. Explained signs of over-exertion and need for rest.
Changes to program: Advised group to focus on controlled movements rather than speed in current exercise set.
Plan:
Sarah:
Continue with app, progress to week 5. Focus on pelvic tilt and glute bridge progression. Recommended using a lumbar support cushion during prolonged sitting.
John:
Continue with app, progress to week 6. Emphasis on chin tucks and scapular retractions. Consider gentle stretching before attending wedding. Booked follow-up session.
Maria:
Continue with app, progress to week 4. Focus on cat-cow and bird-dog exercises. Suggested shorter, more frequent exercise sessions to fit her schedule. Booked follow-up session.
Follow-up recommended and booked for all patients in 2 weeks.
(This note is for a group video consultation typically involving multiple patients and the clinician. For each heading, include all relevant information from the transcript and contextual notes that relates to that heading. Where you are able to identify which patient the information relates to, include their name above that part of the note. Where you are not confident which patient the information relates to, place it under the heading without a name reference. All discussion and education content should be added under the Discussion and Education heading without assignment to individual patient names. Under the Plan section, if an individual patient has been given a modification or variation compared to other patients, make this clear by name; if uncertain who the variation relates to, still include it under Plan without a name. Do not include direct patient quotes in the output.)
Subjective:
[Description of how each patient has been and their current position in the app including week and day number] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
[Description of how each patient has found their exercises] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
[Description of how each patient has been getting on with any advice given and applying it] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
[Miscellaneous details for each patient such as upcoming events or other things happening in their life that may be useful for rapport building in future consultations] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
[Description of any changes in symptoms for each patient] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
[Any other clinically relevant details for each patient] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where the patient can be identified, include their name above the relevant information. Use short sentence structuring and wording even if grammatically incomplete.)
Analysis:
[Structured entry for each patient on the call, including their diagnosis and key notes to retain across visits] (For each patient, present their name as a header above their entry and include the two items below. If nothing new is mentioned in the current transcript or contextual notes, retain and carry forward the information from the previous visit's note. Use short sentence structuring and wording even if grammatically incomplete.
Diagnosis: [Working diagnosis or diagnoses for this patient] (Only include if explicitly mentioned or implied in contextual notes or clinical note, else omit. Do not invent or infer a diagnosis.)
To Note: [Key ongoing notes including goals, preferences, lifestyle factors, medications, and any other details consistently relevant to this patient's care across visits] (Only add or update if explicitly mentioned or implied in transcript, contextual notes, or clinical note, otherwise retain prior note.))
Discussion and Education:
[Detail of any education provided or discussions had relevant to the group, covering topics such as symptoms, diagnosis, upcoming exercises, and any other clinically relevant content] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Do not assign content to individual patient names. Use short sentence structuring and wording even if grammatically incomplete.)
[Detail of any changes to be made to the programme for the coming weeks or days] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Use short sentence structuring and wording even if grammatically incomplete.)
Plan:
[Summary of actionable items, specific advice, any modifications to exercises or programme, and which week or weeks in the app each patient is to progress onto] (Only include if explicitly mentioned or implied in transcript, contextual notes, or clinical note, else omit section entirely. Where an individual patient has a modification or variation compared to others, clearly state their name alongside that item. Where the patient cannot be confidently identified, include the item without a name. Use short sentence structuring and wording even if grammatically incomplete.)
[Follow-up timing and whether it has been recommended and booked] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
