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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Shoulder stiffness and discomfort with overhead reaching, developing gradually over six weeks. Assessment: Movement restriction affecting daily activity. Plan: Agreed a graded home exercise programme and activity modification. Review progress in three weeks. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Shoulder symptoms: Stiffness and pain on overhead reaching for six weeks
functional status
Function: Affects daily activities
plan
Rehabilitation: Graded home exercise programme and activity modification
Review: Review progress in three weeks
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
denials of symptoms
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
Template
Subjective: (hyphenated list) - [Description of current symptoms, including onset, duration, and characteristics (e.g., sharp, dull, radiating)] - [History of present illness or condition leading to consultation] - [Pertinent review of systems, including neurological symptoms, previous injuries, or musculoskeletal conditions] - [Past medical and surgical history, especially related to spine, joints, and musculoskeletal health] - [Lifestyle factors affecting health (exercise habits, occupational hazards, posture, sleep quality, stress levels)] - [Current medications and supplements] - [Family history of musculoskeletal or spinal conditions] Objective: (hyphenated list) - [Vital signs (BP, HR, RR, Temperature)] - [Physical examination findings: posture analysis, spinal alignment, range of motion, muscle tone and strength, palpation for tenderness or abnormalities] - [Neurological assessment: reflexes, sensory testing, motor strength (if indicated)] - [Diagnostic test results, including imaging studies] Assessment: (hyphenated list) - [Chiropractic diagnosis or functional assessment based on findings] - [Identification of areas requiring adjustment or manipulation] - [Diagnosis codes, prioritizing chief complaint and including spinal/extremity subluxations] Plan: (hyphenated list) - [Detailed treatment plan: specific adjustments, manipulation techniques, adjunctive therapies (e.g., soft tissue therapy, therapeutic exercises, modalities)] - [Frequency and duration of treatment plan] - [Short-term and long-term treatment goals] - [Self-care recommendations or home exercises] - [Referrals, if indicated] Interventions: (hyphenated list) - [Details of chiropractic adjustments and other therapeutic interventions performed during the visit] - [Patient's response to treatment, including immediate improvements or adverse reactions] Evaluation: (hyphenated list) - [Evaluation of patient progress towards treatment goals] - [Modifications to treatment plan based on progress and response] Additional Notes: (hyphenated list) - [Patient education provided (ergonomics, lifestyle modifications, preventive measures)] - [Plans for follow-up visits and continued care] - [Patient concerns or preferences]
Shared by
ML
Marie Lefèvre
Physiotherapist, France
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