Acupuncturist Template

Initial Medical Assessment

A professional Acupuncturist template for healthcare professionals.

About this template

Looking for a comprehensive Initial Medical Assessment template? This template is designed for acupuncturists to thoroughly document patient encounters. It covers essential areas like patient history, work status, past medical history, physical examination findings, assessment, goals, and treatment plans. This template helps streamline documentation, ensuring all relevant information is captured. With Heidi, this template can be quickly populated from a visit transcript, saving valuable time and improving accuracy. Start using this template on 1 November 2024 to enhance your clinical documentation process.

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{ "HISTORY": "The patient presents with a chief complaint of lower back pain, which began approximately two weeks ago following a heavy lifting incident. The pain is described as a dull ache, primarily located in the lumbar region, with occasional radiation down the left leg. Aggravating factors include prolonged sitting and bending. Relieving factors include rest and applying heat. There are no associated symptoms such as pins and needles, numbness, weakness, or instability.", "WORK": "The patient works as a construction worker, performing heavy lifting tasks daily. He works five days a week. During work breaks, he typically sits.", "PAST HISTORY": "The patient has a history of occasional headaches, but no other significant medical conditions.", "PAST SURGERY": "The patient has not had any past surgical procedures.", "FAMILY HISTORY": "The patient's father has a history of arthritis.", "GENERAL HEALTH": "The patient generally considers his health to be good, apart from the current back pain.", "HOBBIES": "The patient enjoys playing golf on weekends, which he has had to reduce due to his current condition.", "SOCIAL": "The patient lives with his wife and two children.", "TREATMENTS": "The patient has tried over-the-counter pain relievers, which provided minimal relief. He has not received any other treatments.", "MEDS": "The patient is currently taking ibuprofen 200mg as needed for pain relief, which provides some relief.", "INVESTIGATIONS": "No investigations have been performed.", "EXAM": "On physical examination, the patient exhibits tenderness to palpation in the lumbar region. Range of motion is limited, particularly with forward flexion. The straight leg raise test is positive on the left side at 45 degrees. There is no evidence of neurological deficits.", "ASSESS": "The patient is assessed to have lumbar strain with possible radiculopathy.", "GOALS": "The patient's goals are to reduce pain and return to work as soon as possible.", "PLAN": "The plan includes acupuncture treatments twice a week for the next four weeks. The patient is advised to avoid heavy lifting and prolonged sitting. Follow-up appointment scheduled in two weeks. Referral to a physical therapist for further evaluation and exercises." }

HISTORY: [document the patient's chief complaint, including onset, aggravating factors, relieving factors, location of pain, radiation, and associated symptoms such as pins and needles, numbness, weakness, or instability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) WORK: [describe the patient's current work status, including work days per week and any physical activities performed during work breaks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PAST HISTORY: [detail any relevant past medical history, particularly concerning the chief complaint or other significant conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PAST SURGERY: [list any past surgical procedures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) FAMILY HISTORY: [document any relevant family medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) GENERAL HEALTH: [describe the patient's overall general health status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) HOBBIES: [describe the patient's hobbies and how they relate to or are affected by their current condition, including any new activities started] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) SOCIAL: [document the patient's social situation, including household members] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) TREATMENTS: [list past and current treatments for the chief complaint, including medications, injections, and therapies, and their effectiveness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) MEDS: [detail current medications, including over-the-counter and as-needed medications, and their perceived effectiveness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) INVESTIGATIONS: [summarize results of relevant diagnostic investigations, including imaging findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) EXAM: [document relevant physical examination findings, including patient general appearance, range of motion, special tests, and palpation findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) ASSESS: [provide a clinical assessment or diagnosis based on the history and examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) GOALS: [document the patient's stated goals for treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PLAN: [outline the proposed management plan, including referrals to other healthcare professionals, follow-up appointments, and specific recommendations for exercises or activity modifications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (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.)

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