Postnatal Pelvic Floor Physiotherapy Assessment

(Never invent or assume any patient details, assessments, plans, interventions, or clinical information. Use only the transcript, contextual notes, or clinical note as the source for all information.) Patient Details [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Patient's date of birth] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Patient's contact details] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Patient's GP name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Patient's occupation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Date of assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Postnatal stage in weeks, months, or years] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) Subjective Assessment Obstetric History [Number of pregnancies and births, type of deliveries including vaginal, assisted, or caesarean section, perineal trauma including tear grade or episiotomy, baby weight or weights, and any complications such as postpartum haemorrhage, pre-eclampsia, or gestational diabetes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Current Concerns [Main goals, urinary symptoms, bowel symptoms, prolapse symptoms, pain symptoms, and sexual function concerns as reported by the patient] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each concern as a separate bullet point.) Bladder Function [Urinary frequency, nocturia, leakage details including timing, amount and triggers, urgency symptoms, and fluid intake information] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Bowel Function [Bowel movement frequency, stool type using the Bristol Stool Chart, straining, incomplete emptying, and pain during bowel movements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Sexual Function [Pain with intercourse, vaginal dryness, and confidence returning to sexual activity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Exercise And Activity [Current activity level, pre-pregnancy activity level, exercise goals, and barriers to exercise] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) General Health [Sleep quality and patterns, mental health status, C-section scar issues, and current medications] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Consent Internal Exam Consent Obtained: [Whether internal examination consent was obtained, recorded as yes or no] (Only include if an internal examination is explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Chaperone Offered: [Whether the chaperone offer was accepted or declined] (Only include if a chaperone is explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Objective Assessment Posture And Breathing [Postural alignment observations, rib cage position, breathing pattern including apical versus diaphragmatic, and ability to coordinate breath with movement] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Abdominal Assessment [Visual assessment findings, doming or coning observations, tissue quality, palpation findings, diastasis recti width in finger widths or centimetres, depth and tension, and location above, at, or below the umbilicus] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) C-Section And Perineal Scar [Scar healing status, mobility, sensitivity, and presence of adhesions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Pelvic Floor Assessment [External observation findings, perineal movement with cough, and ability to contract and relax the pelvic floor] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) [Internal assessment tone recorded as low, normal, or high] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence on a single line.) Power: [Modified Oxford Scale grade out of 5] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Endurance: [Duration of hold in seconds] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Repetitions: [Number of long holds completed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Fast: [Number of fast contractions completed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Elevation: [Whether finger elevation was present, recorded as yes or no] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Co-Contraction: [Whether co-contraction was present, recorded as yes or no] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) Timing On Cough: [Contraction timing during cough recorded as normal or slow] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.) [Relaxation ability and prolapse assessment using the POP-Q system where performed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Functional Assessment [Squat, single leg balance, lunge, load transfer, impact tolerance, and return-to-run readiness assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each assessment as a separate bullet point.) Assessment Summary [Key findings, clinical reasoning, identified impairments, and rehabilitation priorities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Treatment Plan Education [Pelvic floor function education, pressure management education, and bladder and bowel habits education provided during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Exercise Programme [Pelvic floor training exercises, core rehabilitation exercises, functional strength exercises, and mobility work, including sets, repetitions, holds, and frequency where stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each exercise as a separate bullet point.) Lifestyle Advice [Lifting technique advice, return to exercise guidance, and toileting posture advice] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Goals [Short-term and long-term rehabilitation goals as stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each goal as a separate bullet point.) Follow-Up Plan [Review timeframe and progression markers] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each item as a separate bullet point.) Email Summary (Only include this entire section if an exercise programme or advice was explicitly provided in the transcript, contextual notes, or clinical note. If neither was provided, omit this section entirely.) Dear [Patient's first name], (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit the name and write "Dear," without a name.) "It was a pleasure to meet you today." "This email is a summary of our session." Key Findings And Reassurance [A summary of the key assessment findings written in patient-friendly language, including reassurance that the findings are common and treatable] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in plain language in full sentences, with each sentence as a separate paragraph.) Advice Points [A summary of the lifestyle and habit advice provided during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each piece of advice as a separate bullet point in plain language.) Your Exercise Programme "Please perform these exercises as discussed." "Focus on the quality of the contraction and, just as importantly, the full relaxation afterwards." [A detailed patient-friendly description of each exercise including sets, repetitions, hold durations, and frequency as discussed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Present each exercise as a separate bullet point with parameters listed as sub-bullet points.) "I look forward to seeing you for your review in" [the review timeframe as stated]. (Only include the review timeframe if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit the timeframe and write the sentence without it.) "Please keep a note of your symptoms in the meantime." "Best wishes," [Clinician's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.) [Clinician's title] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)