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Clinical Exercise Specialists
15-20 minutes

Initial Evaluation Note for EP Template

The EP Initial Assessment Note template by s10.ai is expertly crafted for Exercise Physiologists to meticulously document comprehensive initial patient assessments. Featuring sections for referral information, medical and social history, exercise regimens, and treatment strategies, this template empowers clinicians to accurately capture both subjective and objective findings, establish precise goals, and delineate a clear management plan. Perfect for cases involving musculoskeletal conditions, chronic pain, and exercise interventions, it ensures a structured approach to patient care, enhancing communication and continuity. Optimized for seamless integration with s10.ai, the AI medical scribe, this template is an essential tool for clinicians seeking to elevate their practice.

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Jordan Mitchell
Template Structure

Organized sections for comprehensive clinical documentation

Referral type: [Specify type of referral such as Medicare, DVA, Workers Compensation, and the total number of sessions along with the current session count].
Reason for referral: [Explain the reason for referral and expectations for the current consultation. Describe the progression of the complaint and the nature of symptoms. List any aggravators or relievers in separate sections and in bullet point format (mention only if applicable and available)].
Subjective:
Medical History:
- [List all relevant current and past medical history, e.g., diabetes, stroke, cardiovascular disease, etc.]
Musculoskeletal:
- [List any noted musculoskeletal injuries/considerations, the specific location, year of diagnosis (if known) i.e. R meniscal tear, L rotator cuff tear, etc.] (include a brief description and how currently managed)
- [Detail any previous surgeries/treatments or scans and results] (Only include if explicitly mentioned and applicable)
Medications:
- [List all named current medications and previous medications (if mentioned include dosage,
(include a brief description and how they are managing each condition, e.g. Amlodipine 5mg QD] (Only include if explicitly mentioned)
- [Mention any allergies] (Only include if explicitly mentioned)
Social History:
- [Summarize lifestyle factors including living arrangements, social network, pets (if applicable)]
- [Summarize employment status, including volunteering and level of employment e.g. full-time, retired, part-time (if applicable)]
- [Mention any smoking, alcohol use (if applicable frequency and amounts)]
Exercise History:
Current: [Detail current exercise routine - include frequency, type, and duration/amount i.e. 3 days per week, walking 45 minutes or 3 sets x 10 reps]
Previous: [Detail any previous exercise routine, include frequency, type, and duration/amount i.e. 3 days per week, walking 45 minutes or 3 sets x 10 reps]
Barriers:
-[List any barriers affecting progress, i.e. motivation, time, cost, etc.] (Only include if explicitly mentioned)
Goals:
- [List 1 - 3 goals that are: specific, measurable, attainable, realistic, and timely goals]
Objective:
- [List all physical observations and examinations completed, along with their findings] (Always group relatable findings together, for example, active range of motion measures must be situated in the one section)
- [List any questionnaires used, the scoring, and note they are stored on file with the current date]
Treatment:
- [List all educational treatment provided e.g. pain education, exercise guidelines for specific conditions, physiology around condition] (Only include if explicitly mentioned)
- [Title section either Exercise Program or Home Exercise Program whichever is appropriate, include current plan detailing frequency, intensity, type of exercise, and any warnings provided] (Group types of exercise together e.g. aerobic including walking, rowing, swimming, etc., and list resistance in bullet points such as 3 x 10: Squats, calf raises, push-ups, etc.)
Assessment:
- [Therapist's professional opinion based on medical history, musculoskeletal, social history, current exercise history, objective (if applicable and available)]
- [Summarize the assessment and state findings based on subjective and objective findings] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
Plan:
- [Briefly summarize clinical plan until next appointment, list responsibilities of client and clinician]
- [Timeline to next review e.g., review in 1/52]
- [Briefly note any referrals to other allied health/medical professionals and/or any already scheduled appointments stating with whom and note stated dates] (Only include if explicitly mentioned)
- [Briefly reference exercise plan with frequency and type per week e.g. aerobic 2 days per week, strength/resistance 3 days per week, balance daily and/or flexibility 4 days per week]
- [Briefly note factors affecting progress and any need for modification in the plan (if applicable)]
Sample Clinical Note

Example of completed documentation using this template

Referral type: Medicare, Total number of sessions: 10, Current number of sessions: 1.
Reason of referral: The patient has been referred for the management of persistent lower back pain. The goal is to enhance mobility and decrease pain levels. The condition has been worsening over the past 6 months, with increased morning stiffness.
Aggravators:
- Extended periods of sitting
- Lifting heavy items
Relievers:
- Application of heat
- Gentle stretching exercises
Subjective:
Medical History:
- High blood pressure
- Type 2 Diabetes
Musculoskeletal:
- L4-L5 disc herniation identified in 2021, currently being managed with physiotherapy and pain relief medication.
Medications:
- Metformin 500mg twice daily
- Amlodipine 5mg once daily
Social History:
- Resides with spouse and two children
- Employed full-time as an accountant
- Non-smoker, occasional alcohol consumption (1-2 drinks weekly)
Exercise History:
Current: Walking 3 times per week, 30 minutes each session
Previous: Gym workouts 2 times per week, 1-hour sessions
Barriers:
- Limited time due to work commitments
Goals:
- Increase walking to 5 times per week
- Decrease pain levels by 50% within 3 months
- Enhance flexibility and strength in the lower back
Objective:
- Active range of motion: Restricted flexion and extension in the lumbar region
- Strength testing: Core muscle weakness
Treatment:
- Provided pain education
- Home Exercise Program: 
  - Aerobic: Walking 4 times per week, 30 minutes
  - Resistance: 3 sets of 10 repetitions of squats, lunges, and core exercises
Assessment:
- The patient exhibits chronic lower back pain likely resulting from L4-L5 disc herniation. Contributing factors include limited range of motion and core muscle weakness.
Plan:
- Continue with the current exercise regimen, review in 2 weeks
- Patient to keep a daily exercise log
- Referral to physiotherapist for additional manual therapy
- Exercise plan: Aerobic 4 times per week, resistance training 3 times per week
- Monitor progress and adjust the plan as necessary
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient patient care management. By incorporating high-search healthcare and clinical keywords, this template facilitates the detailed recording of referral types, reasons for referral, and subjective assessments, including medical and musculoskeletal history. It also covers medication details, social and exercise history, and identifies potential barriers to progress. The objective section allows for precise documentation of physical examinations and findings, while the treatment section provides space for educational interventions and exercise programs. The assessment and plan sections enable clinicians to summarize professional opinions and outline future care strategies, including timelines and referrals. This template is an essential tool for clinicians seeking to enhance patient outcomes through meticulous and organized documentation. Explore and implement this template to optimize your clinical workflow and improve patient care delivery.
Frequently Asked Questions

Common questions about this template and its usage

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