Physiotherapy Initial Assessment

Goals - [Patient's goals for treatment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Subjective** PC [Presenting complaint or diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) HPC [Detailed history of presenting condition including when it started, duration, progression, and whether symptoms have improved or worsened] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Neuro - [Neurological symptoms if present] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Aggs - [Movements or activities that worsen symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Keep brief.) Eases - [Movements or activities that improve symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Keep brief.) 24hr - [Pattern of symptoms throughout the day] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Hx injury - [Previous injuries or surgeries] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Social Hx - [Patient's occupation and detailed work setup] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading.) PA - [Physical activity patient participates in with detailed description] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading.) General Health Sleep - [Hours of sleep and quality] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading. Keep concise.) Stress - [Stress level: high, medium, or low] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Smoke - [Yes or no] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading.) Drink - [Yes or no] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading.) PMH - [Past medical history] (Describe in detail, only include relevant past medical history if explicitly mentioned in transcript, contextual notes, or clinical note. If not mentioned, write nil.) DH - [Drug history] (Describe in detail, only include relevant drug history if explicitly mentioned in transcript, contextual notes, or clinical note. If not mentioned, write nil.) Red Flags - [Red flag symptoms if present: night pain, unremitting pain, hot or cold sweats, sudden onset of new pain, hot to touch, changes in colour, swelling, feeling under the weather, inflamed joints, inability to weight bear, bilateral pins and needles, saddle anaesthesia, sexual dysfunction, urinary incontinence, involuntary eye movements, nausea or vomiting, numbness in face or extremities, dizziness, double vision, speech difficulties, swallowing difficulties, drop attacks] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not omit the heading.) ICE: I - [Patient's ideas about their condition and what they think might be causing it] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) C - [Patient's concerns] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) E - [Patient's expectations from the session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Investigations - [Details of any scans including when and where performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Objective** [Physical examination findings including observation, palpation, range of movement, strength testing, special tests, functional assessments, and any objective measurements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) HEP: [Exercises prescribed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List exercise names only, numbered, with each on a new line. Do not include repetitions or sets.) **Analysis** [The clinician's stated clinical analysis and reasoning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Plan** FU [Number of weeks until next appointment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Rv [What will be reviewed in next session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)