Physical Medicine & Rehabilitation / Physiatry Consult

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

Physical Medicine & Rehabilitation / Physiatry Consult

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Structure symptoms, functional limitations, and associated information into distinct paragraphs. Include onset, duration, progression, aggravating/relieving factors, prior interventions, and impact on activities of daily living. Use full sentences and formal clinical language.)

Past Medical History:
(hyphenated list)
- [Relevant medical conditions, including neurological, musculoskeletal, and other chronic illnesses]

Surgical History:
(hyphenated list)
- [Surgical procedures with year if known]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Baclofen 10 mg oral TID)

Allergies:
(hyphenated list)
- [e.g., No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Father: stroke)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Mobility aids: type and use]
- [Support systems: caregivers, family involvement]

Functional Status:
(hyphenated list)
- [Ambulation: independent, with device, wheelchair, etc.]
- [Transfers: independent, assisted, dependent]
- [Activities of daily living (ADLs): bathing, dressing, toileting, feeding]
- [Instrumental ADLs: cooking, shopping, finances, transportation]
- [Bladder/bowel function: continence, catheter use, bowel program]
- [Communication/cognition: any deficits]

Review of Systems:
(hyphenated list)
- [Pertinent positives and negatives relevant to the consult]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Musculoskeletal: tone, bulk, strength (by muscle group), range of motion, deformities]
- [Neurological: sensation, reflexes, coordination, cranial nerves if relevant]
- [Gait and balance: description or limitations]
- [Skin: pressure injuries, wounds, integrity]
- [Other relevant systems as indicated]

(Frequently used exam terminology includes... )

(When I state Normal '___', input '__________________')



Investigations:
(hyphenated list)
- [Relevant imaging, labs, or other studies with results and units]

Assessment & Plan:
[One-sentence patient summary including age, sex, primary diagnosis, and functional status]

#) [Diagnosis or problem as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Rehabilitation goals]
- [Therapies recommended (PT, OT, SLP, etc.)]
- [Assistive devices or equipment needs]
- [Medications or interventions]
- [Patient/family education and counselling]
- [Referrals to other services]
- [Follow up plan]
- [Return precautions]