"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session"
Patient Information:
Jane Doe, Age: 34 years and 6 months, Female
Works as a teacher, job involves standing for long periods.
Regularly attends Pilates classes twice a week.
Lives with her husband and two children, has a supportive family environment.
Context:
Husband present for part of the session.
Referred by Dr. Smith, GP.
Subjective:
Chief complaints: Urinary incontinence when coughing or sneezing, pelvic heaviness, and occasional lower back pain. Requests information on pelvic floor exercises.
Symptoms started approximately 6 months ago, worsening over the last month. Located in the pelvic region, with radiation to the lower back. Described as a feeling of pressure and a dull ache.
Symptoms are exacerbated by coughing, sneezing, and prolonged standing. Relieved by lying down.
Symptoms have gradually worsened over time.
No previous episodes of similar symptoms.
Impacts daily activities, particularly during exercise and social outings.
Pelvic Health Symptoms:
* Urinary incontinence with coughing and sneezing.
* Urgency to urinate.
* Frequency of urination approximately every 2-3 hours.
* Drinks approximately 2 litres of water per day.
* Bowel movements are regular, with no issues.
* Eats a balanced diet with plenty of fruits and vegetables.
* Reports a feeling of pelvic heaviness.
Past Medical History:
No significant past medical or surgical history.
No relevant social history related to presenting issues.
No relevant family history related to presenting issues.
Patient Goals:
Short-term physiotherapy goals: Reduce urinary incontinence episodes within 4 weeks.
Long-term physiotherapy goals: Improve pelvic floor strength and function, and return to full participation in exercise and social activities within 3 months.
Objective:
Consent for examination was obtained verbally prior to the assessment, explaining the nature of the examination and the patient's right to withdraw consent at any time.
* Pelvic floor muscle assessment: GH+PB, Prolapse: Grade 1, Strength: 3/5, Tone: Normal, Relaxation: Normal, Endurance: Reduced.
* Musculoskeletal assessment: Gait normal, ROM normal, muscle strength normal.
* No investigations completed.
Issues:
Urinary Incontinence
- Impression: Stress urinary incontinence.
- Differential: Urge incontinence, mixed incontinence.
- Interventions performed during session: Education on pelvic floor anatomy and function, instruction in pelvic floor muscle exercises (Kegels), and lifestyle advice.
- Patient response to interventions: Patient demonstrated correct technique for pelvic floor muscle exercises.
- Patient education and counselling provided: Education on bladder diary, fluid intake, and avoidance of bladder irritants.
Evaluation:
Patient demonstrates understanding of pelvic floor exercises and is motivated to improve.
Home Program:
Prescribed pelvic floor muscle exercises (Kegels) 3 times a day, holding for 5 seconds, and repeating 10 times. Advised to keep a bladder diary.
Handouts:
Provided patient with a handout on pelvic floor exercises and bladder retraining.
Plan:
Follow-up appointment scheduled in 4 weeks.
No need for a letter to the referring provider.
Planned treatments for ongoing issues: Continue with pelvic floor muscle exercises, bladder retraining, and lifestyle advice.
No referrals to other healthcare providers.
"Notes transcribed via Heidi Health - patient consented verbally prior to commencing session"
Patient Information:
[Name], Age: [age in years and months], [gender/sex]
[Employment status, physical demands of job, work-related activities] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[General exercise and physical activity levels] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Social history including family, home environment, and support at home] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Context:
[Other persons present and their relationship to the patient] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Referring clinician or health professional] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Subjective:
[Chief complaints, reasons for visit, requests or symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Duration, timing, location, quality, severity, context of symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Exacerbating or relieving factors, including self-treatment attempts and effectiveness] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Symptom progression over time] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Past episodes of similar symptoms including management and outcomes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Impact on daily activities, work and lifestyle] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Pelvic Health Symptoms:
[Bladder symptoms including frequency, urgency, incontinence, pad usage, voiding difficulties etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Fluid intake summary] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Bowel symptoms including frequency, stool type, urgency, incontinence, difficulties etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Dietary intake summary] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Prolapse-related symptoms in female patients] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Leave blank if patient is male.)
[Sexual function symptoms including erectile dysfunction, dyspareunia etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Associated symptoms (systemic or focal)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Past Medical History:
[Relevant past medical and surgical history, investigations or treatments related to presenting issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Relevant social history related to presenting issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Relevant family history related to presenting issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Other relevant subjective information] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Patient Goals:
[Short-term physiotherapy goals and timeframes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Long-term physiotherapy goals and timeframes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Objective:
[Consent for examination including what was consented to and how consent was obtained] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Pelvic floor muscle assessment findings including method of assessment, consent, and clinical findings such as gh+pb, prolapse, strength, tone, relaxation, endurance] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[Musculoskeletal assessment including gait, movement, ROM, muscle strength (excluding pelvic floor)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Completed investigations and their results] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Do not include planned investigations.)
Issues:
[Issue, condition or request name]
- Impression: [Diagnosis or clinical impression] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Differential: [Differential diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Interventions performed during session including exercises, manual therapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Patient response to interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Patient education and counselling provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
(Repeat this Issues block as many times as needed based on the number of issues discussed.)
Evaluation:
[Progress towards treatment goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Home Program:
[Prescribed home exercises, self-management advice, stretches or techniques] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Handouts:
[Handouts or educational leaflets provided to patient physically or via email] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Plan:
[Follow-up timing and review schedule] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Need for letter to referring provider] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Planned treatments for ongoing issues] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Referrals to other healthcare providers] (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, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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.)
