Sport Medicine Consult

APPOINTMENT DATE: [appointment date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) REASON FOR REFERRAL [Describe the reason for referral, including affected side, affected joint(s), and primary symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING ILLNESS [Describe the primary complaint in detail, including onset, mechanism, symptom location and quality, severity, radiation, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Describe aggravating and relieving factors, previous treatments, relevant surgical history, and current functional limitations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include the patient’s perception of progression, current status, and goals for the appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICAL HISTORY [List relevant past and current medical conditions, including surgeries or comorbidities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS [List current medications with dosage and indication if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES [List allergies and type of reaction if known] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY [Describe occupation, physical activities, and relevant lifestyle factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PHYSICAL EXAMINATION [Provide a narrative summary of relevant physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) IMAGING [Summarize relevant imaging findings from available reports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) IMPRESSION [Summarize the clinical impression and list diagnoses or differential diagnoses in order of priority] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PLAN [Outline the treatment plan including recommended interventions, investigations, prescriptions, activity modification, referrals, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include short- and long-term goals and expected outcomes where relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PROCEDURE NOTE [Include procedure note section if a procedure was performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Document the procedure performed, including substance administered, anatomical site, laterality, and use of image guidance if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include consent statement confirming risks, benefits, alternatives, and consent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include procedural details such as site preparation, technique, equipment, medications used, and patient positioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include post-procedure outcome, tolerance, and aftercare advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention immediate response to the procedure if reported] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I have explained to the patient that an AI-assisted scribe will be used for note-taking during the assessment. Verbal consent was obtained, and this note was generated using this technology to ensure accuracy and efficiency in documenting the assessment. Time Spent with Patient: [total transcription recording time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Start Time: [Start time as per recording start time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in 24-hour format.) End Time: [End time as per recording start time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in 24-hour format.) (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 include 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.)