Clinical Documentation Summary - Royal Australian College of General Practitioners (RACGP) Template

Administrative Details
- Date of request: 1 November 2024
- Received from: s10.ai
- Claim number: 123456789
- Patient name: John Doe
- Patient date of birth: 15 March 1980
- Practice name: Green Valley Medical Centre
- GP name: Dr. Emily Carter
- GP credentials: MBBS, FRACGP
General Practitioner Credentials
- Report Prepared By: Dr. Emily Carter, MBBS, FRACGP
This report has been prepared by Dr. Emily Carter, an MBBS, FRACGP with 15 years of experience in general practice. I have been treating John Doe since 1 January 2020, and I am their usual GP.
Purpose and Scope:
This report has been prepared at the request of s10.ai to provide medical information regarding John Doe's chronic lower back pain. The report is based on medical records and includes details of the patient's condition, treatment, investigations, and referrals. There may be some gaps in the medical record where relevant.
Subjective Findings
Demographic and Contextual Factors:
- Age: 44, Occupation: Office Manager
- Work Environment: Sedentary job with prolonged sitting
Symptoms (Patient-Reported):
- Persistent lower back pain, stiffness, occasional radiating pain to the left leg
- Reported Improvement: Pain relief with physiotherapy sessions
Impact on Lifestyle:
- Time Off Work: 2 weeks medical leave in the past year
- Functional Limitations: Difficulty in prolonged sitting and lifting heavy objects
- Workplace Adjustments: Ergonomic chair and standing desk provided by employer
Objective Findings
Medical History & Diagnosis:
- First Presentation: 1 January 2020
- Diagnosis: Chronic lower back pain, diagnosed on 15 January 2020
Test/Investigation Results:
- MRI on 20 January 2020: Mild disc bulge at L4-L5
Medical Management to Date:
Medications:
- Ibuprofen 400mg, twice daily as needed
Referrals:
- Referred to physiotherapy on 1 February 2020
Hospitalizations:
- None
Procedures/Therapies:
- Physiotherapy sessions twice a week
Ongoing/Planned Management
Medications:
- Continue Ibuprofen as needed
Referrals:
- Follow-up with physiotherapist scheduled for 15 November 2024
Hospitalizations/Procedures/Therapies:
- Ongoing physiotherapy sessions
Prognosis:
- Prognosis: Good with continued physiotherapy and ergonomic adjustments
Medical Opinion / Response to Requested Questions:
John Doe's condition affects his ability to perform tasks that require prolonged sitting or heavy lifting. Ergonomic adjustments at the workplace have been beneficial.
I confirm that the information in the above report is true and correct. This report will not be altered but I will provide a supplementary report with more details should it be deemed necessary.
Certification and Signature
GP’s Name and Signature: Dr. Emily Carter
GP’s Phone Number: 0123 456 789
GP’s Email Address: emily.carter@gvmedical.com
Date: 1 November 2024