HumanisRx - Care Plan

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™

Template

HumanisRx - Care Plan 

PATIENT INFORMATION
First Name: [First name]
Last Name: [Last name]
Date of Birth: [yyyy-mm-dd]
Gender: [Gender]
Policy #: [Policy number]
PID: [PID]
Phone: [Phone number]
Email: [Email]

REASONS FOR REFERRAL
[Reason(s) for referral]
DMSO: [DMSO]
Drug File Attached: [Yes/No]

HEALTHCARE PROVIDERS
Primary Care / Family Doctor
Name: [Name]
Address: [Address]
Tel #: [Telephone number]
Fax #: [Fax number]

Community Pharmacy
Name: [Name]
Address: [Address]
Tel #: [Telephone number]
Fax #: [Fax number]

Specialist(s)
Name: [Name]
Tel #: [Telephone number]
Fax #: [Fax number]

MEDICAL CONDITIONS
(hyphenated list)
- [Medical condition 1]
- [Medical condition 2]
- [Medical condition 3]

PATIENT'S CHIEF COMPLAINTS
(hyphenated list)
- [Chief complaint 1]
- [Chief complaint 2]
(+/- to collapse/expand section)

DRUG THERAPY PROBLEM(S) #[Number]    Date Identified: [yyyy-mm-dd]
(hyphenated list for problem type selection)
- [Drug therapy problem]

Subjective:
[Subjective information relevant to DTP]

Objective:
[Objective findings relevant to DTP]
(+ GAD-7, + PHQ-9, + BPI to open questionnaires and auto-calculate scores)
(Repeat DRUG THERAPY PROBLEM section for each identified DTP)

Assessment:
[Assessment of DTP]

Plan:
[Plan to address DTP]

RECOMMENDATIONS
(hyphenated list)
- [Recommendation list]

NEXT STEPS
[Next steps for follow-up or monitoring]