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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
Health Coach Note Date of Encounter: [Date] Client Identification: [Client name, age, gender] Reason for Visit: [Brief statement of client’s main concern, goal, or reason for session] History of Present Illness / Current Status: [Description of client’s current health status, symptoms, or progress towards goals. Include relevant background information, challenges, and successes.] Past Medical History: (hyphenated list) - [Relevant medical conditions] - [Previous surgeries or hospitalizations] - [Chronic illnesses] Medications & Supplements: (hyphenated list) - [Medication or supplement name, dose, frequency] Allergies: (hyphenated list) - [Allergen and reaction] - [e.g., No known allergies] Lifestyle & Social History: (hyphenated list) - [Dietary habits] - [Physical activity level] - [Sleep patterns] - [Stressors] - [Tobacco, alcohol, or substance use] - [Occupation] - [Support system] Assessment: [Summary of client’s current health status, barriers, and strengths. Include readiness to change and motivation.] Goals: (hyphenated list) - [Short-term goals] - [Long-term goals] - [SMART goals if applicable] Plan: (hyphenated list) - [Action steps for client] - [Resources or referrals provided] - [Education or counselling topics discussed] - [Follow-up plan and next appointment date] Client Questions/Concerns: [Document any questions or concerns raised by the client during the session] Coaching Notes: [Additional observations, strategies used, or reflections on the session]
Shared by
ML
Marie Lefèvre
Physiotherapist, France
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