Initial Appointment

HOPC: [Describe the history of the presenting condition, including mechanism and date of onset or injury, symptom progression, and management undertaken since onset or injury] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points to capture all relevant information.) [Describe the aggravating and easing factors for the patient's symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points.) [Describe the behaviour of the patient's symptoms over a 24-hour period] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points.) Radiology: [List any radiology investigations undertaken for the presenting complaint, including the type of imaging and a summary of findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list, with each new investigation on a new line.) Past Medical History: [List existing and past medical conditions, including a brief description of each condition and how the patient is currently managing it, including any relevant medications with dosage and frequency] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) [List any known allergies, including the allergen and nature of the reaction] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) Social History: [Describe relevant social history including lifestyle factors, living arrangements, available support network, and relevant substance use history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points.) [Describe relevant family medical history that may relate to the presenting condition or impact the patient's response to therapy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points.) [Describe the patient's employment status, occupation, typical working hours, and the physical and mental demands of their role] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write using bullet points.) Goals: [List the patient's short-term physiotherapy goals and the expected timeframe for achieving each goal] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list, with each new goal on a new line.) [List the patient's long-term physiotherapy goals and the expected timeframe for achieving each goal] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list, with each new goal on a new line.) Objective: [List all physical observations and examination findings such as active range of motion, strength findings and special orthopaedic tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list, grouping related findings together under subheadings where appropriate.) Treatment: [List all education provided during the session, including the topic and key messages conveyed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) [List all manual and hands-on treatment techniques performed during the session, including the technique, region treated, parameters and repetitions where applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) [List all active therapeutic exercises performed during the session, including the exercise name, target region, sets, repetitions, and any relevant parameters] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) [List all home exercises prescribed, including exercise name, sets, repetitions, and frequency of performance] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a list.) Assessment: [State the primary diagnosis and summarise the clinical reasoning based on subjective and objective findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in full sentences.) [State any differential diagnoses being considered and summarise the supporting clinical reasoning] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in full sentences.) [Summarise the patient's progress towards their stated short-term and long-term goals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in full sentences.) [Describe any identified barriers that may be affecting the patient's progress or response to treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in full sentences.) Plan: [Provide a brief summary of the clinical management plan until the next appointment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in full sentences.) [State the planned timeline for the next review or appointment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write in a bullet point list.) [Describe the likely treatment and interventions planned for the next appointment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a bullet point list.) [List any referrals to other healthcare professionals that have been made or are recommended] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a bullet point list.) [List any correspondence, phone calls, or communications the treating physiotherapist plans to complete before the next session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit entirely. Write as a bullet point list.) (Never include information that has not been explicitly mentioned in the transcript, context or clinical note. If information related to any placeholder has not been explicitly mentioned, leave that section blank without indicating that information is missing. Use as many bullet points as needed to capture all relevant clinical information from the transcript.)