S/
- Client reports increased lower back pain after gardening, rating it a 6/10 on the pain scale.
- Client reports consistent adherence to prescribed core strengthening exercises, performing them 3 times per week.
- Client reports that time constraints are a barrier to exercise participation.
- Symptoms impact daily activities, making it difficult to lift groceries.
- No new medical updates.
Client’s goal is to reduce back pain and improve functional capacity.
O/
- Client demonstrated good form during the plank exercise, with slight lumbar arching noted.
- Heart rate increased to 110 bpm during the exercise session, RPE of 4/10, no reported pain or fatigue.
- Completed the Oswestry Disability Index (ODI) with a score of 24.
- Blood pressure 130/80 mmHg, resting heart rate 70 bpm.
- Client reported feeling a slight increase in back pain during the deadlift exercise.
A/
Exercise Completed:
- Core strengthening exercises: plank (3 sets of 30 seconds), bird dog (3 sets of 10 reps), deadlifts (3 sets of 8 reps) at 10kg, performed with good form.
Assessment:
1. Lower Back Pain
- Differential diagnosis: Lumbar strain, possible facet joint irritation.
- Investigations planned: Review ODI scores at next visit.
- Treatment planned: Continue core strengthening exercises, education on proper lifting techniques, and discuss pain management strategies.
- Relevant referrals: None.
2. Reduced Functional Capacity
- Differential diagnosis: Deconditioning due to pain.
- Investigations planned: Repeat ODI and functional testing in 2 weeks.
- Treatment planned: Progress exercise intensity and duration, encourage regular activity.
- Relevant referrals: None.
Education Provided:
- Provided advice on proper lifting techniques and posture.
- Discussed pacing strategies and the importance of rest.
P/
Follow-Up:
- Next session scheduled for 15 November 2024, in-person.
- Reassess ODI and functional capacity at the next visit.
- No referrals needed.
Monitoring and Safety:
- Monitor for increased pain, numbness, or weakness. Stop exercise if symptoms worsen.
- Report any significant changes in symptoms before the next visit.
Program/ADL Recommendations:
- Continue core strengthening exercises, focusing on proper form.
- Encourage regular walking and light activity.
- Discussed strategies for managing pain and fatigue.
Other Notes:
- Client is motivated to improve and is compliant with recommendations.
S/
- [Client’s current symptoms, complaints, or feedback about previous sessions/exercises] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Reported adherence to prescribed exercise program since last session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Barriers or facilitators to exercise participation noted by client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Impact of symptoms on daily activities or function since last visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Any new relevant medical updates or changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Client’s goals or concerns raised during session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
O/
- [Client’s performance quality, form, and any deviations noted] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Physiological responses observed during session: heart rate, RPE, pain response, fatigue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Functional tests or measures completed during session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Any relevant vitals or physical observations recorded] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Immediate effects or reactions to exercises during session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
A/
Exercise Completed:
- [Exercise session details: exercises completed, sets, reps, intensity, duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assessment:
[1. Issue, problem or request 1 (issue, request, topic or condition name only)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Differential diagnosis for Issue 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Investigations planned for Issue 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Treatment planned for Issue 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Relevant referrals for Issue 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[2. Issue, problem or request 2 (issue, request, topic or condition name only)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Differential diagnosis for Issue 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Investigations planned for Issue 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Treatment planned for Issue 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Relevant referrals for Issue 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[3. Issue, problem or request 3, 4, 5 etc (issue, request, topic or condition name only)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Differential diagnosis for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Investigations planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Treatment planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Relevant referrals for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Education Provided:
- [Relevant advice on condition management, pain, pacing, recovery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Goal setting or motivational support discussed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
P/
Follow-Up:
- [Date/mode of next session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Planned reassessments or outcome measures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Referrals if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Monitoring and Safety:
- [Signs/symptoms to monitor and when to stop or modify exercise] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Instructions on reporting issues before next visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Program/ADL Recommendations:
- [Exercises to be performed independently with instructions/precautions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Strategies for self-monitoring and symptom management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Adherence support or behavioural coaching points] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Other Notes:
[Any additional clinical decisions, client preferences, or contextual factors] (Only include if explicitly mentioned in transcript, context or clinical note, 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 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.)
