"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session"
Patient Information:
Jane Doe, Age: 45 years and 2 months, Female
Subjective:
* Chief complaints or reasons for visit including symptoms or requests: Patient reports ongoing pelvic pain and urinary incontinence.
* Progress or worsening of symptoms since previous session: Symptoms have remained stable, with no significant improvement or worsening.
* Adherence to previous home exercises or advice: Patient reports performing exercises 3 times per week.
* Bladder symptoms including frequency, urgency, incontinence, pad use, voiding dysfunction:
* Urinary frequency: 8-10 times per day.
* Urgency: Moderate.
* Incontinence: Occasional stress incontinence with coughing or sneezing, using 1-2 pads per day.
* Bowel symptoms including frequency, stool consistency, urgency, incontinence, defecation issues:
* Bowel movements: Once daily, normal consistency.
* No urgency or incontinence.
* Prolapse symptoms such as vaginal bulge, heaviness, voiding/defecation issues: Patient reports a feeling of heaviness in the vagina, especially after standing for long periods.
* Aggravating or relieving factors including self-management strategies and their effects: Symptoms are aggravated by prolonged standing and relieved by rest and pelvic floor exercises.
Objective:
* Pelvic floor muscle examination findings including method used, consent, position, gh+pb, prolapse, strength, tone, relaxation, holds etc.:
* Method: Per vaginal examination.
* Consent: Obtained.
* Position: Supine.
* Strength: 3/5.
* Tone: Normal.
* Relaxation: Good.
* Musculoskeletal assessment including gait, movement, ROM, strength of non-PFM muscles:
* Gait: Normal.
* ROM: Within normal limits.
* Strength: Normal.
Patient Goals:
* Short-term physiotherapy goals and expected timeframes: Reduce urinary incontinence episodes within 4 weeks.
* Long-term physiotherapy goals and expected timeframes: Improve pelvic floor muscle strength and function within 12 weeks.
Action Taken:
Pelvic Pain
- Interventions performed including exercises, manual therapies, education: Provided education on pelvic floor anatomy and function. Demonstrated pelvic floor exercises and provided a home exercise program.
- Patient response to interventions: Patient reports understanding the exercises and is willing to perform them.
- Patient education and counselling provided: Discussed lifestyle modifications to manage symptoms.
Urinary Incontinence
- Interventions performed including exercises, manual therapies, education: Provided education on bladder retraining techniques. Demonstrated pelvic floor exercises and provided a home exercise program.
- Patient response to interventions: Patient reports understanding the exercises and is willing to perform them.
- Patient education and counselling provided: Discussed lifestyle modifications to manage symptoms.
Evaluation:
* Progress toward treatment goals: Patient demonstrates understanding of exercises and is motivated to continue with the program.
Home Program:
* Exercises, stretches or self-management strategies prescribed for ongoing care: Pelvic floor muscle exercises (3 sets of 10 repetitions, 3 times per day). Bladder diary.
Plan:
* Next review/follow-up timing: 4 weeks.
* Planned treatment strategies for each issue: Continue with pelvic floor exercises and bladder retraining techniques.
Date: 1 November 2024
"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session"
Patient Information:
[Name], Age: [age in years and months], [gender/sex]
[Occupation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Physical activity, exercise or sports participation and frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Other person present during consult and their relationship to the patient] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Upcoming appointments with specialists or allied health team] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Subjective:
[Chief complaints or reasons for visit including symptoms or requests] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Progress or worsening of symptoms since previous session] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Adherence to previous home exercises or advice] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Bladder symptoms including frequency, urgency, incontinence, pad use, voiding dysfunction] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Bowel symptoms including frequency, stool consistency, urgency, incontinence, defecation issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Prolapse symptoms such as vaginal bulge, heaviness, voiding/defecation issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Leave blank if patient is male.)
[Sexual symptoms including dyspareunia, erectile dysfunction or other sexual function concerns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Aggravating or relieving factors including self-management strategies and their effects] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Objective:
[Pelvic floor muscle examination findings including method used, consent, position, gh+pb, prolapse, strength, tone, relaxation, holds etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Musculoskeletal assessment including gait, movement, ROM, strength of non-PFM muscles] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Investigations with results that were completed and mentioned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Do not include planned investigations.)
Patient Goals:
[Short-term physiotherapy goals and expected timeframes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Long-term physiotherapy goals and expected timeframes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Progress towards physiotherapy goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Action Taken:
[Issue, condition or request name]
- [Interventions performed including exercises, manual therapies, education] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Patient response to interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Patient education and counselling provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
(Repeat Action Taken block for each issue as needed.)
Evaluation:
[Progress toward treatment goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Home Program:
[Exercises, stretches or self-management strategies prescribed for ongoing care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Handouts/Leaflets:
[Written or emailed resources provided to patient] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Plan:
[Next review/follow-up timing] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Whether a letter is to be written back to referring clinician] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Planned treatment strategies for each issue] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Referrals to other healthcare providers] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
(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.)