Hand Therapy - General

Area/s requiring treatment: - [include details of the side of the injury, date of injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [if required surgery, include surgical details such as surgery completed, the surgeon and date of surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Mechanism: - [include details of how injury occurred] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Patient background: - [left or right hand dominant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [employment/work history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - Social factors - [mention who is at home, if caring for anyone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Past Medical History: - [Mention contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention social history that may be relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention family history that may be relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention exposure history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention immunization history & status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Other: Mention any other relevant subjective information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Subjective/current symptoms: - [Mention reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention duration/timing/location/quality/severity/context of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention list anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Progression: Mention describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Mention impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Objective: - [Vitals signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Physical or mental state examination findings, including system specific examination(s)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Investigations: - [Investigations with results] (You must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan. Write in bullet points.) Assessment: - [Likely diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Treatment: - [Include details such as custom made orthosis; wearing regime; exercises prescribed; precautions discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Treatment planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) Plan: - [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) - [Relevant other actions such as counselling, referrals etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in bullet points.) (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.)