Pain Progress Documentation
[patient name] (D.O.B. [patient date of birth, formatted as month date, year])
[Put the date of transcript or encounter here, formatted as month date, year]
Informed Patient Consent was obtained at the beginning of our visit to use s10.ai for documentation
Start time: [use the start time for the session and write it here, formatted as hh:mm in 24 hour format]
SUBJECTIVE & NARRATIVE
Patient reports:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Response to procedures such as nerve blocks done at prior visit. Mention no problems after nerve blocks (only if specifically mentioned) or if there were any problems or concerns after the last procedures (only if specifically mentioned)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
PMHx & OTHER ACTIVE ISSUES
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
SOCIAL & FUNCTIONAL Hx
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention how the patient is managing at home with daily activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention social activity with others, travel plans, exercise etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
MOOD & RELATED ISSUES
- [Mention mental health history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention how is the patient's mood, is mood basically OK and stable?]
OBJECTIVE & O/E:
- Looks well & NAD
- VSS as above
- Vital signs: [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
- [Vitals signs post-procedure (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
IMPRESSION & PROBLEM FORMULATION:
- [Likely diagnoses. Look up the ICD-9 code for each diagnosis, using http://icd9.chrisendres.com and write the ICD-9 code here. Look up the ICD-10 code for each diagnosis, using https://www.icd10data.com, and write the ICD-10 code here]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
PLAN:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Mention if the patient would like to proceed with procedures today]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
"End time:" [use the end time for the session and write it here, formatted as hh:mm in 24 hour format]
"Duration:" [calculate the time duration of the encounter session, and record the time duration here]
[Write the following only if we are planning to do a procedure such as injections today:
"Patient confirms would like to proceed with injections today. Reviewed common and serious risks and complications, specifically relevant to the procedures to be performed in this particular patient. Confirms has read and understood the consent form as previously discussed. Questions, concerns, and comments elicited and addressed. Patient consents to interventional treatments today. Interventions performed as per Intervention Record below."]
[Write the following only if we are planning to do a procedure such as injections today, and there is no mention of complications or problems:
Post-injection patient was well, and mobilizing with no neurologic side effects. No concerns expressed such as worsening pain, shortness of breath, dizziness or weakness.]
"Discharge Assessment:
Reminded patient to wait at least 20-30 minutes in clinic after procedure. Discharge home, contingent upon
Stable vital signs (HR 60-120, and SBP 100-160mmHg), and
Patient denies any dizziness, leg weakness or other weakness, or shortness of breath, and
Patient confirms they are feeling well, and
Patient is walking or otherwise mobilizing well"
(Never come up with your own patient details - use only the transcript, contextual notes or clinical note as a reference for the information included in your note.)
[Clinician Name]
[Clinician Title]