1,497 uses
Patient Handout - 80 Bond
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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Intermittent lower back pain after lifting boxes at work five days ago. No leg weakness, numbness, bladder or bowel symptoms. Assessment: Mechanical low back pain without features of nerve root involvement. Plan: Encouraged gentle activity and simple analgesia as needed. Discussed return precautions and review in two weeks if not improving. 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
Pain: Intermittent lower back pain for five days
history of present illness
Trigger: Started after lifting boxes at work
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
denials of symptoms
Denies: Neurological symptoms: No weakness, numbness, bladder or bowel symptoms
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
assessment
Working diagnosis: Mechanical low back pain
plan
Follow-up: Review in two weeks if not improving
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
Template
Summary of Visit: (Briefly explain the diagnosis in simple, patient-friendly language, and explain what it is to the patient. Do not list subjective or objective information unless relevant. Use full sentences only.) Treatment: (only include this header if treatment mentioned) (hyphenated list, only include new medications started today, do not include reference to medications the patient is already on. Include other treatments that are not medications, e.g. nasal saline, rest, hydration, etc.) - [Medication name, dose, route, frequency if mentioned] - [e.g., Metformin 500 mg by mouth twice daily] Follow-Up Instructions: (only include this header if instructions mentioned) (hyphenated list) - [Bloodwork ordered] (if bloodwork is ordered in the plan, state "Bloodwork can be done at DynaCare or LifeLabs. The nearest location for LifeLabs is at 55 Queen Street East, open 7am-6pm on weekdays. You can book an appointment online or walk-in.") - [Xray ordered] (if xray ordered in the plan, state "X-Rays can be completed at any location with a requisition.") - [Ultrasound ordered] (if ultrasound ordered in the plan, state "Ultrasounds can be completed at any location with a requisition. The nearest location is Metro Ultrasound at 27 Queen Street East, open 8am-5pm on weekdays. You can usually complete a walk-in appointment.") - [MRI or CT scan ordered] (if CT or MRI ordered in the plan, make reference that patient will receive a call to book this and wait time is variable depending on urgency) - [Specialist appointment date and time] (if referral made to specialist in the plan, make reference that patient will receive a call to book this and wait time is variable depending on urgency) - [Follow up appointment date and time] Go to the nearest emergency department if: (hyphenated list) - [life threatening conditions relevant to their diagnosis] If you have any questions or concerns, contact our clinic or seek urgent care. (do not include medical abbreviations in this note, e.g. SOB, CP, BID)
Shared by
MB
Dr. Marc Beaulieu
Family Physician, Canada
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