Functional Capacity Assessment

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Client Information:
(hyphenated list)
- [Client's full name]
- [Date of birth]
- [NDIS participant number]

Assessment Date:
- [Date of assessment]

Assessor Information:
(hyphenated list)
- [Assessor's full name]
- [Assessor's professional title]
- [Assessor's contact details]

Reason for Referral:
- [Reason for referral]

Background Information:
(hyphenated list)
- [Client's medical history]
- [Client's social history]
- [Client's current living situation]

Functional Capacity Assessment:
(hyphenated list)
- [Describe client's physical capacity]
- [Describe client's cognitive capacity]
- [Describe client's communication capacity]
- [Describe client's social and emotional capacity]
- [Describe client's daily living skills]

Summary and Recommendations:
(hyphenated list)
- [Summary of assessment findings]
- [Recommendations for support and services]