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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm. Assessment: Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed. Plan: Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise. 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
Anxiety: Increased anxiety during work-related stress
Sleep: Disrupted sleep
denials of symptoms
Denies: Risk: Denies thoughts of self-harm
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Support: Coping strategies, sleep routine, and follow-up discussed
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.
Template
HOPC - [Describe history of presenting condition, including mechanism and date of injury, management since injury, etc] - [Describe factors that aggravate and ease the pain] - [Describe the pain over the duration of 24 hours] Radiology: - [List any radiology assessment and their findings that have been undertaken for this patient's presenting complaint/injury] Past Medical History - [List existing and past medical conditions, e.g., osteoporosis, stroke, high blood pressure, surgeries etc, with brief description and management, e.g. Amlodipine 5mg QD] - [Mention any allergies] Social History - [Mention relevant social history like lifestyle factors, living arrangements, support network, tobacco/alcohol use, etc] - [Mention family medical history of disease that may be relevant to their presenting condition or may impact their response to therapy] - [Summarise employment status, occupation, hours worked, physical/mental intensity of job, etc] Goals - [Short-term physiotherapy goals & time frame for achieving these goals] - [Long-term physiotherapy goals & time frame for achieving these goals] Objective - [List all physical observations and examinations completed, along with their findings] Treatment - [List all educational treatment provided throughout session, e.g. pain science education] - [List all hands-on treatment provided throughout session, e.g. Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc] - [List all active therapy treatment provided throughout the session, e.g. 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc] - [List home exercise program (HEP) provided, including reps, sets, and frequency] Assessment - [Summarise the assessment and state diagnosis based on subjective and objective findings] - [Summarise the assessment and state differential diagnosis based on subjective and objective findings] - [Summarise their progress towards their stated goals] - [State any barriers affecting progress] Plan: - [Brief summary of the clinical plan until the next appointment] - [Timeline of next review] - [Likely therapy to be provided at next appointment] - [Referrals to other professionals that need to occur or the patient will attend] - [Letters, phone calls, or communication the treating therapist will do before next session]
Shared by
SO
Sarah O’Connell
Mental Health Counselor, Ireland
How it works in Notat
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