Alternative Medicine Initial Evaluation

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Exempel — genererat av Notat från ett exempelbesök

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™

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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]