Sims and Finn Chiropractic Note

[Patient name and/or file number] Today's Condition: [Patient’s response to previous chiropractic treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) [Current issues, symptoms, and reasons for today’s visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) [Description of current symptoms including onset, duration, severity, and characteristics of pain or discomfort] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) [History of present illness or condition leading to the consultation] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) [Review of systems relevant to chiropractic care, including neurological symptoms, previous injuries, or musculoskeletal conditions] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) [Past medical and surgical history relevant to spine, joints, or musculoskeletal health] (Only include if explicitly mentioned; else omit completely. Write as list or narrative.) [Lifestyle factors affecting health such as exercise, occupation, posture, sleep, stress, etc.] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) [Current medications and supplements] (Only include if explicitly mentioned; else omit completely. Write as list.) [Family history of musculoskeletal or spinal conditions] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) Examination: [Physical examination findings including range of motion, palpation, and other relevant tests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Do not include instructions given to the patient during exam, e.g., “bend your knee.” Write in narrative form.) [Vital signs including pulse, blood pressure, temperature] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write as list or narrative.) Chiropractic Adjustments/Treatment: [Chiropractic adjustments or treatments performed during today’s visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) [Details of specific adjustments or therapeutic interventions including area treated, method of administration, dosages/units if relevant, and any adjunctive techniques such as ice or distraction tools] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) [Patient’s response during treatment including immediate improvements or adverse reactions] (Only include if explicitly mentioned; else omit completely. Write in narrative form.) Response to Treatment: [Patient’s immediate response following today’s treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) Home Advice: "10–15 minute walk post adjustment" [Home care advice including exercises, stretches, lifestyle recommendations, or restrictions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) Follow-up: [Recommendation for next visit, including timeframe and follow-up actions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit completely. Write in narrative form.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, omit it completely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)