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Alternative Medicine Initial Evaluation
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Note terminée
Exemple — généré par Notat à partir d'une visite exemple
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.
Modèle
Alternative Medicine Initial Consultation Template Patient Identification: [Patient name, age, gender, presenting concern or reason for visit] History of Present Illness: [Description of current symptoms, onset, duration, progression, associated factors, previous treatments tried, impact on daily life] Past Medical History: (hyphenated list) - [Chronic illnesses] - [Previous surgeries] - [Hospitalizations] - [Significant injuries] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Include supplements, herbal remedies, vitamins] Allergies: (hyphenated list) - [Drug allergies] - [Food allergies] - [Environmental allergies] Family History: (hyphenated list) - [Relevant family medical conditions] - [Hereditary diseases] Social History: (hyphenated list) - [Tobacco use: type, amount, duration] - [Alcohol use: type, amount, frequency] - [Recreational substances: type, amount, frequency] - [Dietary habits] - [Exercise routine] - [Occupation] - [Living situation] Lifestyle and Wellness Practices: (hyphenated list) - [Sleep patterns] - [Stress management techniques] - [Mind-body practices (e.g., yoga, meditation)] - [Complementary therapies used] Physical Examination: (hyphenated list) - [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Relevant system findings] (Format as "System: Exam findings", one system per line) Investigations: (hyphenated list) - [Laboratory or imaging results if available] - [Other assessments relevant to alternative medicine] Assessment: (hyphenated list) - [Summary of findings] - [Working diagnosis or health concerns] - [Contributing factors (physical, emotional, environmental)] Plan: (hyphenated list) - [Recommended alternative or complementary therapies] - [Lifestyle modifications] - [Dietary recommendations] - [Mind-body interventions] - [Follow up plan] - [Referrals to other practitioners if needed] - [Patient education and counselling] - [Return precautions]
Partagé par
ML
Marie Lefèvre
Physiotherapist, France
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