Referral Source:
Patient self-referred.
Subjective:
Chief complaint: Pain in the right heel for 6 months.
Pain is described as a sharp, stabbing pain, worse in the morning and after rest.
No radiation of pain.
Symptoms are bilateral, with mild discomfort in the left heel.
Pain is triggered by walking and standing for long periods.
Associated symptoms include stiffness in the morning.
Pain intensity is rated as 7/10.
Medical history: Patient has a history of plantar fasciitis.
MOTIVATION TO SEEK HELP:
Patient is motivated to reduce pain and improve mobility to be able to walk comfortably and return to their exercise routine.
Objective:
Gait observations: Antalgic gait on the right foot.
Visible swelling noted in the right heel.
Range of motion findings: Decreased dorsiflexion in the right ankle.
Joint-specific observations: Tenderness on palpation of the plantar fascia.
No skeletal abnormalities noted.
Assessment:
1. Plantar fasciitis, right foot.
2. Mild plantar fasciitis, left foot.
Outcome Measures/ Baseline:
Patient needs to reduce pain and improve mobility.
Pain scale results: 7/10 at baseline.
Functional Goals:
Short-term (2-4 weeks):
• Reduce pain to 3/10.
• Be able to walk for 30 minutes without significant pain.
Long-term (8-12 weeks):
• Return to pre-injury activity levels.
• Improve overall foot function.
STERILE PACK NUMBER: 12345
Plan:
Immediate interventions: Ice packs, stretching exercises, and orthotic recommendations.
Patient education provided: Information on plantar fasciitis and home care instructions.
Follow-up timeline: Schedule a follow-up appointment in 4 weeks.
Potential future interventions to consider: Consider corticosteroid injection if symptoms persist.
Plan for reassessment: Reassess pain levels and functional status at the follow-up appointment.
Referral Source:
[Note referral source, or how the patient found our service] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective:
[List patient's chief complaints and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Describe pain characteristics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note any pain radiation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention any bilateral symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Record pain patterns and triggers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Rate pain intensity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Include relevant medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MOTIVATION TO SEEK HELP:
[Identify and summarise the patient's motivations for seeking treatment from the transcript. Include this information in the appropriate section of the clinical note.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
[Describe gait observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note any visible swelling or abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document range of motion findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Record joint-specific observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note any skeletal abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document observations of other joints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[List primary diagnosis] (Write as a numbered list starting from 1 and add more numbered items as needed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List secondary diagnosis] (Write as a numbered list continuing from the previous section and add more numbered items as needed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Outcome Measures/ Baseline:
[Record Patient needs, goals and desired outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Record pain scale results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Functional Goals:
[Short-term (2-4 weeks):
• List specific pain reduction goals
• List specific activity goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Long-term (8-12 weeks):
• List specific activity restoration goals
• List specific functional improvement goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
STERILE PACK NUMBER: [document sterile pack number of any equipment used during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[List immediate interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document patient education provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Specify follow-up timeline] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[List potential future interventions to consider] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Note plan for reassessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, 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, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
