Physio respiratory initial

"Consent was obtained for the session and for the use of Heidi AI Health Scribe." [Family members, clinicians or students present during the session] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) Reason for Referral: [Reason for referral to physiotherapy including a brief summary of the patient's reason for attending] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) History of Presenting Complaint: [Main disability] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Secondary diagnoses or comorbidities] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Date of diagnosis and source] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Hospital discharge date, progress since discharge, previous physiotherapy input and other health professional involvement] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Summary of patient's need for physiotherapy whilst in hospital] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) Complaints: [Clinical complaints related to physiotherapy including worsening pain, problem activities, panic or anxiety, usual and current walking distance and ability, usual and current wheeze or tightness including time of day and triggers, usual and current cough including daily pattern and triggers, sputum colour, amount and consistency, haemoptysis, sleep pattern, dizziness, pins and needles, abdominal upset, anxiety or depression, falls, incontinence, post-nasal drip, congestion, sinusitis, loss of appetite, weight loss and pulmonary rehabilitation] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in bullet point form.) "Medications: See med chart" Past Medical History: [Relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Imaging Results: [Results from radiology imaging including X-rays, CT and MRI] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Medication History: [Current medications and supplements including drug name, dose and frequency] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) [Other therapists involved in the patient's care] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) Social History: [Patient's living situation including type of accommodation, who they live with, occupation past and present, and history of irritant exposure such as asbestos, dust, chemicals and pets] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Patient's previous level of function prior to admission including mobility, personal and domestic activities of daily living such as shopping, cleaning, cooking and bathing, and hobbies or activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Patient's exercise tolerance prior to admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [Current home support services] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) [History of falls in the past 12 months] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write in paragraph format.) Objective: [How the patient was found including position, orientation, oxygen requirements, colour, finger clubbing and oedema] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) Vitals: [Vital signs including RR, HR, SpO2, Borg score, PEFR usual and current, and weight] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write each on its own line.) [Attachments including IDC, IV lines and any other devices] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) Auscultation: [Auscultation findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Lateral Basal Expansion (LBE): [Thoracic lateral basal expansion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Cough: [Clinical description of cough including strength, character and productivity] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) CXR: [Chest X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Breathing Pattern: [Breathing pattern findings including accessory muscle use at rest, broken sentences, inspiratory to expiratory ratio, nasal or mouth breathing, paradoxical breathing, chest shape, chest expansion, cough, huff and sputum] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [Any other relevant clinical information pertinent to an acute hospital physiotherapist] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Mobility: - Supine - SOEOB: [Patient's functional ability to transition from supine to sitting on the edge of the bed] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) - Sitting Balance: [Patient's functional ability to sit independently] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) - Sit to Stand: [Patient's functional ability to transition from sitting to standing including 1-minute sit to stand if performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) - Standing Balance: [Patient's functional standing balance] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) - Transfers: [Patient's functional ability to transfer from one surface to another] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) - Walking: [Patient's functional ability to walk including distance, aid used, level of assistance required, limiting factors, TUG, 6-minute walk test and step ups if performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Musculoskeletal: [Musculoskeletal findings including cervical and thoracic range of motion and upper and lower limb strength] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Treatment: [Treatment provided to the patient during this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Analysis: [Summary of how nurses should transfer and mobilise the patient on the ward, with specific detail regarding level of assistance required] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) [Whether the patient is or is not at baseline function] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) [Whether the patient is safe or not for discharge from physiotherapy including reasoning] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a brief statement.) [Barriers that may affect patient discharge from physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) Plan: [Recommendations for doctors or other members of the multidisciplinary team to action or be aware of] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bulleted list.) [Next physiotherapy review date] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [Goal of the next physiotherapy session] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [Timeline of next review] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [Likely therapy to be provided at the next appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [Letters, phone calls or communications the treating therapist will complete before the next session] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.)