Subjective
How has it been since last session?
- Patient reports significant improvement in low back pain since the last session, with severity decreasing from 7/10 to 3/10. Frequency of pain episodes has also reduced from daily to 2-3 times a week, primarily after prolonged sitting. Functional limitations are less pronounced, now able to walk for longer periods without discomfort.
Any post-treatment soreness?
- Experienced mild, localised soreness in the lower lumbar region for approximately 24 hours after the last treatment, described as a dull ache. It resolved completely with rest and application of a heat pack.
How has your homework been going?
- Patient reports consistent compliance with prescribed core strengthening exercises and stretches, performing them daily as instructed. Feels the exercises have contributed to improved stability and reduced pain intensity.
Progressed towards SMART goals?
- Patient reports being able to tie their shoelaces and lift their grandchild without pain, which were specific goals. They also noted improved sleep quality and reduced reliance on over-the-counter pain medication.
Other:
- Patient mentioned an upcoming short holiday to Cornwall next month and expressed a desire to be as pain-free as possible for hiking activities. Also noted stress at work due to a new project deadline, which occasionally exacerbates their back stiffness.
Objective
Re-Evaluation:
- Numeric Pain Rating Scale (NPRS) decreased from 7/10 at initial assessment to 3/10 today. Oswestry Disability Index (ODI) improved from 36% to 18%.
Observation:
- Posture: Noticeable improvement in lumbar lordosis, appears less exaggerated. Gait: Smoother and more fluid, with less guarding evident during ambulation. No visible swelling or asymmetry.
ROM:
Active / functional:
- Flexion: Full range, smooth movement, minimal end-range discomfort.
- Extension: Improved by 10 degrees compared to last session, slight stiffness at end-range.
- Lateral Flexion (L/R): Left 40 degrees with mild discomfort, Right 45 degrees, pain-free.
- Rotation (L/R): Left 60 degrees, pain-free. Right 55 degrees with mild restriction.
- Other Specific ROM: Lumbar spine flexion-extension test showed improved segmental mobility at L4/L5.
Passive:
- Passive range of motion (PROM) for lumbar spine demonstrates improved elasticity and reduced capsular end-feel. Restriction pattern at L5/S1 noted to be less pronounced.
Neuro-ortho tests / Palpation
Positive - Minor tenderness upon palpation of the right multifidus muscle at L4/L5. Kemp's test positive on the right at end-range flexion and rotation, reproducing a dull ache. Straight Leg Raise (SLR) positive on the right at 70 degrees, eliciting a mild hamstring stretch rather than radicular pain.
NAD - Slump test negative bilaterally. Femoral Nerve Stretch Test (FNST) negative bilaterally.
SMART goal tracking:
Patient's goal to be able to comfortably walk 5 km without pain within the next 4 weeks. This is relevant to them as they enjoy hiking and want to participate fully in their upcoming holiday. Progress is measured by their reported walking distance and pain levels.
Other:
- Postural assessment using a plumb line indicated continued slight anterior pelvic tilt, which will be addressed in future sessions.
Action
Review of Previous Plan:
- Patient confirmed adherence to previous advice regarding ergonomic seating and reported no adverse reactions to the last treatment, including the mobilisation techniques applied.
Manual / Exercise Therapy
- Provided diversified chiropractic adjustments to the lumbar spine at L4/L5 and L5/S1, focusing on restoring segmental motion. Applied gentle soft tissue release to bilateral lumbar paraspinal muscles. Patient gave explicit verbal consent prior to treatment. The aim was to reduce joint restriction and muscle hypertonicity contributing to the reported pain and stiffness.
Advice / Guidance
- Advised patient on maintaining proper posture during prolonged sitting, suggesting regular micro-breaks for stretching. Educated on the importance of hydration and sleep for tissue healing. Emphasised continuing home exercises, particularly core stability work.
Plan
Homework:
- Continue with current core strengthening exercises (plank: 3 sets of 30 seconds; bird-dog: 3 sets of 10 reps each side, daily).
- Add new exercise: Cat-Cow stretch (10 repetitions, twice daily) to improve spinal mobility.
- Advised to use heat pack for 15-20 minutes before performing exercises to aid muscle relaxation.
To do next appointment:
- Re-assess lumbar ROM and palpation findings.
- Review progress on SMART goals and adjust as necessary.
- Progress core strengthening exercises.
- Re-evaluate postural alignment.
Other:
- Schedule next appointment in 1 week to monitor progress closely before holiday. Discuss strategies for managing back comfort during travel.
Date: 1 November 2024
Subjective
How has it been since last session?
- [Describe subjective progress since last session, including symptom severity, frequency, or functional limitations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Any post-treatment soreness?
- [Mention any post-treatment soreness, including onset, duration, and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
How has your homework been going?
- [State patient compliance and perceived benefit of current homework/exercises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Progressed towards SMART goals?
- [Specific subjective update on progress towards agreed-upon SMART goals, including patient-reported function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other:
- [Any other subjective information] (Note any other information they mention, such as personal life or work activities, any upcoming holidays or plans, any extra detail they mention about their personality or context between the sessions. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective
Re-Evaluation:
- [Re-tested objective measure or pain score compared to previous sessions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Observation:
- [Describe key observations: posture, gait, swelling, visible asymmetry, or guarding] (Include any details about the visible appearance of the patient. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ROM:
Active / functional:
- Flexion: [Active ROM findings for flexion, including quality and end-feel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Extension: [Active ROM findings for extension, including quality and end-feel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Lateral Flexion (L/R): [Active ROM findings for lateral flexion left and right, including quality and end-feel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Rotation (L/R): [Active ROM findings for rotation left and right, including quality and end-feel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Other Specific ROM: [Specific active ranges of motion or functional tests mentioned by the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Passive:
- [Passive range of motion (PROM) findings, including end-feel and restriction pattern] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neuro-ortho tests / Palpation
Positive - [List specific positive neuro-orthopaedic tests and palpable tender/restricted structures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What hurts or feels tight/tender and when, and what neuro-orthopaedic tests are positive, which side and to what extent?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
NAD - [List specific tests that were No Abnormality Detected] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What doesn't hurt or feels fine] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SMART goal tracking:
(If there have been any updates about their goals, setting new ones or giving up on old ones: [What are the patient's goals for treatment outcomes? Mention the specific goal, how it is measured, why it is relevant to them, and the expected time frame to achieve this goal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.))
Other:
- [Any other relevant objective findings or measurable data] (Include any other information about their objective findings, like measurable data or further testing. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Action
Review of Previous Plan:
- [Review of patient adherence to prior advice and confirmation of absence of adverse reaction to last treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Manual / Exercise Therapy
- [Detailed list of treatment provided: techniques, areas/joints, duration, sets/reps of exercise therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [What hands-on manual therapy was provided during the session? Did the practitioner seek consent? Was it given?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Include further details about the hands-on manual therapy given such as why it was offered or not offered, information about the style of manual therapy or reasoning behind offering it, and what to expect. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Advice / Guidance
- [Specific advice and guidance given to the patient during the session] (What advice, guidance, or education was given during the session? Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan
Homework:
- [New or adjusted exercises/activities prescribed, including dosage (sets/reps/frequency)] (Use a separate bullet point for each task. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
To do next appointment:
- [Plan for the next session: re-tests, treatment focus, and progression strategy] (Bullet point a list of what the practitioner should do at the next appointment. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other:
- [Other planning notes, e.g., referral plan, consultation frequency] (Include any additional information about the treatment plan going forward, such as preferred treatment frequency, items to monitor at future sessions, or relevant administrative details. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(AI Instructions:
1. Source of Truth & Confidentiality: Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care. Use only the content explicitly mentioned in the dictated transcript, contextual notes or clinical notes as a reference for the information to include in your note.
2. Clinical Tone: Maintain a concise, professional, and clinical style throughout the note, mirroring the language a UK chiropractor would use for SOAP notes.
3. Placeholder Omission: If any information related to a placeholder (text inside [ ]) 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 bullet point blank.
4. Plan Fallback Rule: If the 'To do next appointment' section is blank in the transcript, copy and paste whatever was performed in the 'Manual / Exercise Therapy' section above, formatting it as a bulleted list, to serve as the default plan for the next session.
5. Formatting: Transcribe the dictated notes into the structured format above, strictly adhering to the headings and list format. Do not include these bracketed AI instructions or any instructional text in the final output.)
