Current Condition/Complaint:
- The patient reports a significant reduction in pain since the last appointment.
- No new symptoms or complaints have been presented.
- The patient has been diligent with the home exercise program, completing exercises daily.
- The patient has been using ibuprofen as needed for pain management.
- A recent MRI showed mild disc bulging at L4-L5 with no nerve impingement.
Objective:
- Active Range of Motion (AROM):
- Lumbar flexion: 70 degrees
- Lumbar extension: 20 degrees
- Strength Testing:
- Quadriceps: 5/5 bilaterally
- Hamstrings: 5/5 bilaterally
- Palpation:
- Tenderness noted in the lower lumbar paraspinals
Treatment:
- Educational Treatment:
- Discussed pain management strategies and the importance of posture.
- Hands-On Treatment:
- Mobilisation: Gr II PA R) L4/5 2x30secs
- Unilateral soft tissue massage upper L) calf
- Active Therapy Treatment:
- 3x10 Single leg calf raises
- 3x10 L) ankle knee to walls
- Home Exercise Program (HEP):
- 3x15 bridges, daily
- 2x20 clamshells, daily
Assessment:
- The patient is showing good progress with a reduction in pain and improved mobility.
- The diagnosis remains consistent with lumbar strain with mild disc bulging.
- The patient is progressing well towards their goal of returning to recreational running.
- No significant barriers affecting progress have been identified.
Plan:
- Continue with the current home exercise program and add resistance band exercises.
- Review in 2 weeks.
- Likely therapy at the next appointment will include progression of strengthening exercises and further manual therapy.
- No referrals to other professionals are needed at this time.
- The therapist will send a progress update to the patient's primary care physician before the next session.
(You are a highly skilled physiotherapist with a goal helping your patients improve their pain and function. You are empathetic and want your patient's to achieve their goals)
Current Condition/Complaint:
[Summarise progress of presenting complaint/injury/issue since previous physiotherapy appointment] (Only include if explicitly mentioned)
[Summarise any new symptoms or complaints the patient may present with] (Only include if explicitly mentioned)
[Summarise patient's adherence to the plan since previous physiotherapy appointment, for example, only completed home exercises once, etc] (Only include if explicitly mentioned)
[Summarise patient's medication usage for the presenting complaint/injury/issue] (Only include if explicitly mentioned)
[State any radiology assessment and their findings that have been undertaken for this patient's presenting complaint/injury since last physiotherapy appointment] (Only include if explicitly mentioned)
Objective:
[List all physical observations and examinations completed, along with their findings] (Always group relatable findings together, for example, active range of motion measures must be situated in the one section)
Treatment:
[List all educational treatment that was provided throughout session, e.g. pain science education] (Only include if explicitly mentioned)
[List all hands on treatment provided throughout session, for example, Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc] (Only include if explicitly mentioned)
[List all active therapy treatment provided throughout the session, for example, 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc] (Only include if explicitly mentioned)
[List home exercise program [HEP] provided] (Include reps, sets and frequency) (Only include if explicitly mentioned)
Assessment:
[Summarise the assessment and state diagnosis based on subjective and objective findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Summarise overall progress of patient's issue since presenting to physiotherapy] (Only include if explicitly mentioned)
[Summarise their progress towards their stated goals] (Only include if explicitly mentioned)
[State any barriers affecting progress] (Only include if explicitly mentioned)
Plan:
[Brief summary of the clinical plan until the next appointment] (Only include if explicitly mentioned)
[Timeline of next review, e.g, r/v 2/52] (Only include if explicitly mentioned)
[Likely therapy I will provide at our next appointment] (Only include if explicitly mentioned)
[Referrals to other professionals that need to occur or the patient will attend] (Only include if explicitly mentioned)
[Letters, phone calls or communication the treating therapist will do before next session (Only include if explicitly mentioned)
(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 section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
