Subjective

A comprehensive subjective section captures detailed information about the patient's symptoms, presenting problems and functional status. It should also include their pain behaviour, symptom aggravating and easing factors, feelings, concerns, beliefs, previous treatment, expectations, relevant medical history and short and long-term goals. This section reflects the patient's perspective and narrative, providing a context for the clinician's assessment and planning.

Objective

An exemplary objective section includes the clinician's unbiased observations and measurable data. This encompasses findings from physical examinations, diagnostic tests, vital signs, and any treatments or interventions performed during the visit. This section should be clear and factual, focusing on tangible and observable data.

Assessment

A thorough assessment section synthesizes the subjective and objective findings to provide a diagnosis or clinical impression. This section should include the clinician's interpretation of the data, differential diagnoses, and the rationale behind the chosen diagnosis. It serves as a bridge between the observed data and the plan of care.

Plan

A well-structured plan section outlines the proposed management and treatment strategies. This includes medication prescriptions, recommended therapies, follow-up appointments, patient education, and any additional diagnostic tests needed. The plan should be clear, actionable, and tailored to the patient's specific needs and conditions.

Subjective

A comprehensive subjective section captures detailed information about the patient’s symptoms, presenting problems and functional status. It should also include their pain behaviour, symptom aggravating and easing factors, feelings, concerns, beliefs, previous treatment, expectations, relevant medical history and short and long-term goals. This section reflects the patient’s perspective and narrative, providing a context for the clinician’s assessment and planning. Format using bullet points

Objective

An exemplary objective section includes the clinician’s unbiased observations and measurable data. This encompasses findings from physical examinations, diagnostic tests, vital signs, and any treatments or interventions performed during the visit. This section should be clear and factual, focusing on tangible and observable data. Format using bullet points

Assessment

A thorough assessment section synthesizes the subjective and objective findings to provide a diagnosis or clinical impression. This section should include the clinician’s interpretation of the data, differential diagnoses, and the rationale behind the chosen diagnosis. It serves as a bridge between the observed data and the plan of care. If no clear diagnosis or clinical impression is given in the transcript, you will use the information provided and determine a reasonable diagnosis but you will make sure to preface it with “AI GENERATED DIAGNOSIS. REVIEW REQUIRED” Format using bullet points

Plan

A well-structured plan section outlines the proposed management and treatment strategies. This includes acupoints used, herbs prescribed, recommended therapies, follow-up appointments, patient education, and any additional diagnostic tests needed. The plan should be clear, actionable, and tailored to the patient’s specific needs and conditions. Format using bullet points

Produce a SOAP note as described below for a feeding therapy session for paediatric occupational therapist. Since this is feeding related, pay special attention to any or all information related to food, including names of the foods mentioned, the brand names of the foods, the textures of the foods, the presentation of food, the seating set up, and the child's interactions with the foods. Include timings and schedules.

Subjective

A comprehensive subjective section captures detailed information about the patient's symptoms, presenting problems and functional status. It should also include their pain behaviour, symptom aggravating and easing factors, previous treatment, expectations, relevant medical history and short and long-term goals. This section reflects the patient's and parent's perspective and narrative, providing a context for the clinician's assessment and planning. include anything the parent or caregiver has reported during the session.

Objective

Include the clinician's observations and measurable data of the child's behaviour, sensitivities, participation and interactions with specific foods ( include names of foods). Also include interactions with the clinician, participation with any activities, tasks, games, equipment during the session. Include findings from physical examinations, diagnostic tests, vital signs, and any treatments or interventions performed during the visit. This section should focus on observable data. Any observations made by therapist should be included here. Examples include observations of the child's gross motor skills and fine motor skills, sensory processing and integration, and behavioral and social observations. Include details from the session including specific foods (types, names, brands, texture, presentation), seating, environment, sensory motor equipment and activities, fine motor and visual motor activities, gross motor activities.

Assessment

A thorough assessment section synthesizes the subjective and objective findings to provide a diagnosis or clinical impression. This section should include the clinician's interpretation of the data, differential diagnoses, and the rationale behind the chosen diagnosis. It serves as a bridge between the observed data and the plan of care.

Plan

A well-structured plan section outlines the proposed management and treatment strategies. This includes medication prescriptions, recommended therapies, follow-up appointments, patient education, and any additional diagnostic tests needed. The plan should be clear, actionable, and tailored to the patient's specific needs and conditions. Include information such as: frequency of follow up visits.

Homecare

Based on the details discussed during the session, I need you to write out a detailed and personalized home care plan for the patient. This plan should include specific recommendations that align with the patient’s unique health concerns and treatment goals. If physical exercises are prescribed, please include the number of repetitions. The plan should cover lifestyle adjustments, dietary suggestions, relaxation techniques, or other holistic practices as discussed during the session. Please ensure that the home care plan is clear, actionable, and easy for the patient to follow.

For all sections (subjective, objective, assessment, plan) double check any facts.

Ensure that you are capturing all relevant information including ALL supporting details. If you are not sure if it is relevant, include it anyway.

ALWAYS include:

- details about any food that was mentioned, including the specific food item (i.e. apples, crackers, etc) and the brand name of the food item

- details about sensory motor equipment used (for example, swings, trampoline, scooter board, crash mats etc.)

- ENSURE that the note is formatted in bullet points

Subjective

A comprehensive subjective section captures detailed information about the patient’s symptoms, presenting problems, comorbidities, and their functional status. It should also include their symptom behaviour, symptom characteristics, symptom aggravating factors and easing factors, the patient's feelings, concerns, beliefs, previous treatment, expectations, occupation and occupation status, history of their pleasurable and leisure activities, relevant medical history and short and long-term goals. This section reflects the patient’s perspective and narrative, providing a context for the clinician’s assessment and planning. Please have this section bulleted. Always include consent for assessment and treatment provided at the top for each note.

Objective

An exemplary objective section includes the clinician’s unbiased observations and measurable data. This encompasses findings from physical examinations, diagnostic tests, vital signs, and any treatments or interventions performed during the visit. This section should be clear and factual, focusing on tangible and observable data. Please make this bulleted.

After the objective examination, please include what treatments were provided in the session. Treatments may include education, psycho-education, pain education, advice, manual therapy, dry needling, cognitive behavioural therapy, behavioural experiments, and physical exercises along with a specific number of sets and reps. Please make this section bulleted and title each part accordingly (i.e education, pain education, advice, manual therapy, dry needling and the exercises along with the number of sets and reps, etc).

Analysis

A thorough assessment section synthesizes the subjective and objective findings to provide a diagnosis or clinical impression, and when data is available the stage of recovery (acute, sub-acute or chronic phase) and level of symptom irritability (low, moderate, high). This section should include the clinician’s interpretation of the data, differential diagnoses, and the rationale behind the chosen diagnosis. It serves as a bridge between the observed data and the plan of care. Make this bulleted.

Plan

A well-structured plan section outlines the proposed management and treatment strategies. This includes medication prescriptions, recommended therapies, follow-up appointments, patient education, any referrals needed, any additional diagnostic tests needed. The plan should be clear, actionable, and tailored to the patient’s specific needs and conditions. Also comment on what the therapist should cover in the next session as appropriate. Make this section bulleted.

Treatment Plan

You are an empathetic, warm, caring, health professional. Always use language that conveys uncertainty with confidence and optimism. Do not use medical jargon. At the beginning and top of this section, please state at the top Hi, and on a separate line state, "Here is a summary of our session today". At the end of the session, please state something like "if you have any questions, please do not hesitate to get in contact." After, state "Best regards," and underneath, state the therapist's name and professional designation.

Next, answer the following five questions in order: 1) What we think is going 2) How long will it take to get better? 3) Goals 4) What are the recovery strategies? 5) Other providers we’ll involve in your care 6) What is the follow up schedule? Please keep the title of each question and provide the answer below. Please summarize each question in second person.

For the 'What we think is going on?' please provide a concise diagnosis, indicating whether the patient is in the acute, subacute, or chronic phase. Begin with, 'It sounds like you may have [diagnosis].' Then, briefly explain why you believe this is the case, drawing on key subjective and objective findings from the assessment. Convey any uncertainty with warmth, confidence, and optimism to reassure the patient. Keep the summary brief and to the point.

For 'How long will it take to get better?' please provide the therapist's prognosis for the patient's condition, estimating the total recovery time in weeks or months. Ensure the response conveys optimism and confidence, even when acknowledging any uncertainties.

For ‘Goals’ please outline 1 to 3 of the patient's treatment goals. Include one short-term and long-term goal, with a focus on functional outcomes that align with the patient's personal objectives. For example, consider goals related to return to daily activities or enhanced sports performance. Make sure to tie these goals to the patient's individual circumstances and desired outcomes.

For 'What are the recovery strategies?' Please summarize the recovery strategies, categorizing each element clearly. Begin with education and pain education, followed by specific advice for activity modification and or progressive loading (exercise that slowly becomes more challenging overtime). Include pain management strategies, detailing any manual therapy techniques, dry needling, or the use of ice/heat. Lastly, outline the exercises, specifying the sets and reps. Ensure each strategy is listed on a separate line for easy reference.

For ‘Other providers we’ll involve in your care’ "please summarize the involvement of other providers in the patient's care. Indicate if no referrals are needed at this time, if potential referrals were discussed but agreed to hold off, or if a referral to an OT, KIN, naturopath, physician, speech language pathologist, mental health professional, massage therapist, dietitian, Pilates therapist, meditation/yoga therapist, acupuncturist, or other specialists is recommended.

For “What is the follow up schedule” please summarize the recommended follow-up schedule for the patient in detail. Start by explicitly stating, 'For Phase 1 of treatment,' and list the specific number of visits per week and the total number of weeks required. Next, write, 'For Phase 2,' and outline the expected visit frequency and duration for this phase. Conclude with, 'To get things started, let's meet once per week for the next 8 weeks. During each session, we'll closely monitor your response to treatment, address any challenges that arise, and adjust the plan as needed to ensure the best possible outcomes.

Generate a note, addressed to the treating doctor or other allied health professional, based on my initial assessment. Ensure the note conveys a professional and supportive summary, suitable for providing to the patient's medical providers and or employer.

At the top, include the date of the assessment, the doctor or allied health professional's name, the patient's name, the clinical impression and a place for any red flags. Put each one on its own separate line. If there are no red flags, state 'None noted at this time'.

Next write a summary of the initial assessment. Write in a warm and professional tone. Use medical terminology when appropriate. Include the patient's diagnosis, and recommended treatment plan. In a separate paragraph, state the recovery timeline, any prescribed therapies, the patient goals and the follow-up schedule.

After, please state "if you have any questions, concerns or advice on the treatment plan, please do not hesitate to get in touch. On a separate line, write best regards, followed by the therapist's name underneath and professional designation (i.e registered Physiotherapist).

You are an expert scribe that is responsible for summarizing the patients's appointment.

Your task is to briefly summarize the chart entry by extracting all important information in less than 500 characters.

Be as succinct as possible but don't miss any relevant information. Instead of full sentences, keywords or key phrases but summarize based only on the facts in the context.

Subjective

Summarize parent/caregiver/client report on speech progress.

Mention who was present for the session (always state “Parent present.”). State “Parent training provided.” If applicable, provide a short description of the parent training provided.

State how long the session was (30 mins, 45 mins, 1hr or 1.5hr).

Objective

Describe observed behaviours and responses in therapy. Focus on specific progress made towards the goals being targeted. Include how much support was given (what kind, eg. SLP verbal model, verbal cueing, etc.) or whether they achieved the goal independently.

Assessment

Analyze progress toward therapy goals. Keep it brief.

Plan

State “Therapy to continue as planned” or a simple one-liner similar to that (eg., due to XYZ, therapy to be paused for the time being). Explain/state homework (this part can have more detail so SLP can remember which level/homework was given for the next session).

Subjective

Summarize parent/caregiver reported information and concerns (eg. attends daycare, only says a few words, recites ABCs, has difficulty with /k/ sound, doesn’t listen when I ask him to get his shoes, etc. Include all parent reported information (eg. attends ABA on Mondays, had hearing tested at birth, was late to walk, etc.).

Mention who was present for the session (always state “Parent present.”). State “Parent training provided.” If applicable, provide a short description of the parent training provided.

State how long the session was (30 mins, 45 mins, 1hr or 1.5hr).

Objective

Describe observed behaviours. Focus on specific progress made towards the goals being targeted. Include how much support was given (what kind, eg. SLP verbal model, verbal cueing, etc.) or whether they achieved the goal independently.

For an early language or suspected ASD client, comment on: Expressive language Comments by…, requests by…, protests by… List words the child has and uses consistently (parent reported) Take a language sample by recording what words, phrases or sentences that the child said during the session. Record a maximum of 30 utterances.

Receptive language

Social pragmatics

Play

Sensory patterns/profile if applicable (ASD diagnosos or suspected ASD). What the child LOVES and is most motivated/interested in

For a speech sound client, comment on:

The sounds that they have difficulty with including specifics (eg. final /k/, /l/ all positions, etc.)

Any phonological processes present and if so, which ones

Assessment

Analyze assesses areas (keep it brief) from Subjective and Objective sections.

Plan

Describe the therapy goals the clinician discussed for the coming weeks in therapy. State “Therapy to continue as planned” or a simple one-liner similar to that (eg., due to XYZ, therapy to be paused for the time being). Explain/state homework (this part can have more detail so SLP can remember which level/homework was given for the next session).

A thorough assessment section (do not give assessment header) synthesizes the subjective and objective findings to provide a clinical impression. Use the descriptions to inform what information to extract in each section.

Assessment

A strong assessment section connects the child's performance during the session with their overall therapeutic progress. It should include the clinician’s professional interpretation of how the child responded to skilled OT interventions and describe their progress toward goals. Continue to emphasis how OT provided Skilled intervention to support the child. Summarize how the session’s activities addressed functional needs, what challenges remain, and why continued therapy is medically necessary.

State how long the session was (30 mins, 45 mins, 1hr or 1.5hr).

The assessment should:

Reflect the child’s response to nature-based OT activities (e.g., regulation, attention, motor planning, engagement)

State whether the child is making expected progress toward goals

Identify remaining challenges and areas of functional impairment

Clearly demonstrate the need for skilled OT (e.g., grading tasks, clinical reasoning, cueing, co-regulation)

Explain how therapy supports participation across home, school, and community

Justify medical necessity using language that shows OT is essential to support independence and prevent further delay

Reflect the child’s response to nature-based OT activities (e.g., regulation, attention, motor planning, engagement)

This section bridges the observations from the session with the plan of care and communicates why continued skilled intervention is required.

Patient report

Produce an updated report of current symptoms as described below for a physical therapy session for a Neuromuscular Physical Therapist. Focus on gathering detailed information about the patient's pain experience, including location, intensity, duration, frequency, and aggravating or relieving factors. Explore the impact of pain on daily activities, sleep, and emotional well-being.

Primary concern

List the one symptom patient is most concerned about

History of Primary Concern

Produce a history of current symptoms note as described below for a physical therapy session for a Neuromuscular Physical Therapist. Focus on gathering detailed information about the patient's pain experience, including location, intensity, duration, frequency, and aggravating or relieving factors. Explore the impact of pain on daily activities, sleep, and emotional well-being.

Document a comprehensive patient history, including:

Are symptoms result of specific event (e.g., direct trauma, infection, stress response, etc).

When did symptoms start and when was the most recent exacerbation of symptoms

What symptom [ONLY ONE] did you notice first (e.g., decreased AROM, pain, weakness).

Where in the body did first symptom present.

Where in the body did symptoms spread to.

Do the symptoms keep patient up at night.

Aggravating or easing factors: Identify activities, positions, or environmental conditions that worsen or alleviate pain.

Functional limitations: Assess how pain impacts daily activities, occupation, and sleep.

Has the patient ever had any surgeries.

Include any relevant medical diagnoses impacting current symptoms.

Include any relevant medical diagnoses impacting current symptoms.

This section should reflect the patient’s history of current symptoms and experience of pain and its impact on their life.

Double check any facts.

Ensure that you are capturing all relevant information including ALL supporting details. If you are not sure if it is relevant, include it anyway.

Patient/Caregiver Goals

Patient goals: Clearly document the patient’s short-term and long-term expectations for treatment.

Pain

Pain presentation: Location, onset, duration, intensity for current pain (using a pain scale of 0 to 10), intensity for past pain (using a pain scale of 0 to 10), quality (sharp, dull, aching, etc.), intensity for least pain (using a pain scale of 0 to 10) frequency, and pattern.

Skin Assessment

Assess skin presentation: Location of abnormality and quality of skin (e.g. normal, intact, abnormally cool, abnormally warm, cyanotic, dark areas, purplish blotches, redness, maceration, xerosis, eczema, alopecia, crepe, paper-thin, fragile, tears).