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Eksempel — generert av Notat fra et eksempelbesøk
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.
Mal
Subjective: (hyphenated list) - [Chief complaint or reason for visit] - [Relevant relevant history and associated information in chronological order] Objective: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant) - [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan) Assessment: (hyphenated list) - [Diagnosis and reasoning] (Use medical terminology if appropriate. Do not re-state all past medical history unless relevant) - [Differential diagnosis if mentioned] Plan: (hyphenated list) - [Investigations planned or ordered] - [Treatment plan] - [Counselling discussion] - [Referrals sent] - [Follow up plan] - [Return precautions]
Delt av
MB
Dr. Marc Beaulieu
Family Physician, Canada
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