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Sports Medicine Consultation Note
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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™
symptoms
Breathlessness: Progressive exertional breathlessness over two months
denials of symptoms
Denies: Associated symptoms: No chest pain at rest or syncope
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
medications
Current treatment: Continue established medicines pending review
plan
Investigations: Outpatient investigations arranged
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
Sports Physician Note Patient Identification: [Patient name, age, gender, relevant athletic background, presenting complaint] History of Present Illness: [Description of presenting complaint, including onset, duration, mechanism of injury, aggravating and relieving factors, associated symptoms, previous treatments or interventions, impact on athletic performance] Past Medical History: (hyphenated list) - [Relevant medical conditions] - [Previous injuries or surgeries] Medications: (hyphenated list) - [Medication name, dose, route, frequency] Allergies: (hyphenated list) - [Drug/other allergies] Family History: (hyphenated list) - [Relevant family medical history] Social History: (hyphenated list) - [Tobacco use] - [Alcohol use] - [Recreational drug use] - [Occupation] - [Level and type of sport participation] - [Training regimen] - [Recent changes in activity or equipment] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [General appearance] - [Inspection: swelling, deformity, discoloration] - [Palpation: tenderness, crepitus, warmth] - [Range of motion: active and passive] - [Strength testing] - [Special tests relevant to injury] - [Neurovascular status] - [Other relevant systems] Investigations: (hyphenated list) - [Imaging results (e.g., X-ray, MRI, US) with findings] - [Laboratory results] - [Other relevant tests] Assessment & Plan: [One-sentence summary including age, sex, sport, and primary diagnosis] #) [Diagnosis or problem as numbered item] (hyphenated list with each corresponding plan item on a new line) - [Further investigations planned or ordered] - [Treatment plan (e.g., rest, physiotherapy, medications, bracing, surgery)] - [Rehabilitation plan] - [Return to play recommendations] - [Counselling and education] - [Referrals to other specialists if needed] - [Follow up plan] - [Return precautions]
Shared by
DV
Dr. Daniel Visser
Geriatrician, Netherlands
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