Initial diagnosis: Right shoulder impingement syndrome
Mechanism of injury or cause: Gradual onset, exacerbated by overhead activities at work.
Date of initial appointment: 1 November 2024
Referral source: Self-referral
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Clinical Summary
Key findings at initial assessment: Limited active range of motion in shoulder abduction and external rotation. Positive Neer's and Hawkins-Kennedy tests. Palpable tenderness over the supraspinatus tendon.
Treatment interventions provided: Manual therapy to address joint restrictions, soft tissue massage, and education on activity modification.
Response to treatment: Reported reduction in pain levels and improved shoulder movement after the first two sessions.
Residual symptoms or functional limitations: Occasional pain with overhead activities and some stiffness in the morning.
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Functional Outcomes
Functional goals achieved: Able to reach overhead without pain, improved ability to perform daily tasks.
Outcome measures used: Shoulder Pain and Disability Index (SPADI) score reduced from 45/100 to 15/100.
Client satisfaction and engagement: Client reported high satisfaction with the treatment and actively participated in the home exercise program.
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Ongoing Management Plan
Recommended home exercises: Scapular stabilisation exercises, rotator cuff strengthening exercises, and stretching exercises.
Advice on activity/lifestyle: Advised to avoid prolonged overhead activities and to take regular breaks.
Red flags or signs to monitor: Monitor for any increase in pain or loss of function.
Suggested review timeframe: In 3 months
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Communication and Documentation
Discharge summary sent to referral source: No
Client copied into discharge email: No
Insurance provider updated: Not required
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Post-Discharge Engagement
Relevant tag for future updates: Shoulder pain
Added to check-in / newsletter list: Yes
Ongoing service recommendation: Pilates
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Internal Business Notes
Client status updated in Cliniq Apps: Yes
Added to CRM or check-in calendar: Yes
Testimonial or review follow-up: Sent a follow-up email to request a review.
Suitable for case study: Consider in future
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Additional Notes
Client is a keen golfer and is keen to return to the sport. Discussed a graded return to golf program.
Initial diagnosis: [Insert diagnosis]
Mechanism of injury or cause: [Insert mechanism of injury]
Date of initial appointment: [Insert date]
Referral source: [Insert referring consultant, GP or self-referral]
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Clinical Summary
Key findings at initial assessment: [Insert summary of assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment interventions provided: [List key interventions used during care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Response to treatment: [Insert how the client responded over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Residual symptoms or functional limitations: [Insert residual symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Functional Outcomes
Functional goals achieved: [List achieved goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Outcome measures used: [Insert outcome tools or scores] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Client satisfaction and engagement: [Brief summary of how the client responded and participated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Ongoing Management Plan
Recommended home exercises: [Insert list or link to HEP if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Advice on activity/lifestyle: [Include ergonomic, pacing, sport-specific or recovery advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Red flags or signs to monitor: [Insert any cautionary advice given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Suggested review timeframe: [e.g. ad hoc / in 3 months / before ski season] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Communication and Documentation
Discharge summary sent to referral source: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Client copied into discharge email: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Insurance provider updated: [Yes / No / Not required] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Post-Discharge Engagement
Relevant tag for future updates: [e.g. Running injuries, Workplace setup, Pilates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Added to check-in / newsletter list: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Ongoing service recommendation: [Insert Pilates, classes or workshops suggested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Internal Business Notes
Client status updated in Cliniq Apps: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Added to CRM or check-in calendar: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Testimonial or review follow-up: [Insert outcome or action] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Suitable for case study: [Yes / No / Consider in future] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Additional Notes
[Insert any useful personal, lifestyle or professional notes to support future rebooking or engagement] (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.)
