(Only summarise and reformat information provided in the transcript, contextual notes, or clinical notes. Do not add diagnoses, management plans, or clinical recommendations. Do not generate new clinical content. If left or right in relation to the relevant body part is not specifically mentioned in the transcript, omit body site laterality completely. Never omit the year of birth when a date of birth is mentioned. Do not say "this woman" if the template says "this lady". Do not say "this man" if the template says "this gentleman". If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical notes, omit that placeholder completely.)
(Use the patient's gender as stated in the transcript, contextual notes, or clinical notes to determine whether to use "this gentleman" or "this lady", "his" or "her", and "Mr" or "Ms" throughout the document.)
History:
[A narrative summary of the presenting complaint including the duration of the current condition, the body part affected and laterality where stated, any previous musculoskeletal injections received including whether they were carried out at the clinic, the date of any previous injection, the type of injection, the body part injected, and the substance injected, the main medical conditions and clinical information from the clinical notes and transcript, aggravating and easing factors, relevant medical history including medications, and any previous investigation reports] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit section entirely. Write in narrative paragraphs of full sentences. Always include previous investigation reports in the history where mentioned.)
Clinical Findings:
[Physical examination findings including active or passive range of motion, special tests, palpation, and any other relevant assessments] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit section entirely. Write in narrative paragraphs of full sentences. Do not use bullet points.)
Ultrasound Scan:
[Description of the ultrasound scan findings, potential treatment options discussed including injection therapy, and conclusion of the scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit section entirely. Write in narrative paragraphs of full sentences. Do not use bullet points.)
Conclusion:
[The main findings from the history, clinical examination, and ultrasound scan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit section entirely. Present each finding as a separate bullet point.)
Intervention:
(If no injection or procedure was carried out, write "None" and omit all further content in this section.)
(If any procedure was carried out, include the following two sentences using the patient's gender as stated in the transcript, contextual notes, or clinical notes:)
[Sentence confirming the findings were discussed with the patient and that therapeutic options including injection therapy were discussed] (Only include if a procedure was carried out and explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence in the format "The findings were discussed with this [lady/gentleman]. We also discussed therapeutic options, including injection therapy.")
[Sentence confirming the patient agreed with the suggested procedure] (Only include if a procedure was carried out and explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence in the format "Following this discussion, [Mr/Ms] [patient surname] agreed with the suggested procedure.")
(If a steroid injection was given, include the following sentences inserting the relevant values from the transcript, contextual notes, or clinical notes into each placeholder:)
[Sentence confirming informed consent was obtained in accordance with the completed and signed online informed consent form and that the patient read the steroid injection information leaflet explaining risks and side effects] (Only include if a steroid injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Use the patient's correct pronoun as stated.)
[Sentence confirming the ultrasound probe was cleaned with the probe cleaning solution used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence confirming the skin was prepared and cleaned with the skin preparation solution and concentration used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence documenting the ultrasound-guided injection of Depo-Medrone including the dose in mg, expiry date, and batch number, mixed with lidocaine including the concentration, volume in ml, expiry date, and batch number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence confirming the procedure was uneventful and the steroid was accurately placed in the anatomical site of injection] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Include the anatomical site only if explicitly stated.)
(If a hyaluronic acid injection with Durolane was given, include the following sentences inserting the relevant values from the transcript, contextual notes, or clinical notes into each placeholder:)
[Sentence confirming informed consent was obtained in accordance with the completed and signed online informed consent form and that the patient read the hyaluronic acid injection information leaflet explaining risks and side effects] (Only include if a Durolane injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Use the patient's correct pronoun as stated.)
[Sentence confirming the ultrasound probe was cleaned with the probe cleaning solution used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence confirming the skin was prepared and cleaned with the skin preparation solution and concentration used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence documenting the ultrasound-guided injection of Durolane including the dose in mg, batch number, and expiry date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence confirming the hyaluronic acid was accurately deposited in the anatomical site of injection and that the procedure was uneventful] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Include the anatomical site only if explicitly stated.)
(If a hyaluronic acid injection with Ostenil+ was given, include the following sentences inserting the relevant values from the transcript, contextual notes, or clinical notes into each placeholder:)
[Sentence confirming informed consent was obtained in accordance with the completed and signed online informed consent form and that the patient read the hyaluronic acid injection information leaflet explaining risks and side effects] (Only include if an Ostenil+ injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Use the patient's correct pronoun as stated.)
[Sentence confirming the ultrasound probe was cleaned with the probe cleaning solution used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence confirming the skin was prepared and cleaned with the skin preparation solution and concentration used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence documenting the ultrasound-guided injection of Ostenil+ including the dose in mg, batch number, and expiry date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence confirming the hyaluronic acid was accurately deposited in the anatomical site of injection and that the procedure was uneventful] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Include the anatomical site only if explicitly stated.)
(If an Arthrosamid injection was given, include the following sentences inserting the relevant values from the transcript, contextual notes, or clinical notes into each placeholder:)
[Sentence confirming informed consent was obtained in accordance with the completed and signed online informed consent form and that the patient read the Arthrosamid injection information leaflet explaining risks and side effects] (Only include if an Arthrosamid injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Use the patient's correct pronoun as stated.)
[Sentence confirming the ultrasound probe was cleaned with the probe cleaning solution used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence confirming the skin was prepared and cleaned with the skin preparation solution and concentration used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence documenting the initial ultrasound-guided injection of lidocaine including the volume in ml, concentration, expiry date, and batch number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence documenting the subsequent injection of Arthrosamid including the number of syringes, volume per syringe in ml, batch number, and expiry date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence confirming the injected substance was accurately deposited in the anatomical site of injection and that the procedure was uneventful] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Include the anatomical site only if explicitly stated.)
(If a hydrodistension injection was given, include the following sentences inserting the relevant values from the transcript, contextual notes, or clinical notes into each placeholder:)
[Sentence confirming informed consent was obtained in accordance with the completed and signed online informed consent form and that the patient read the steroid injection information leaflet explaining risks and side effects of steroid injections] (Only include if a hydrodistension injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Use the patient's correct pronoun as stated.)
[Sentence confirming the ultrasound probe was cleaned with the probe cleaning solution used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence confirming the skin was prepared and cleaned with the skin preparation solution and concentration used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely.)
[Sentence documenting the ultrasound-guided injection of Depo-Medrone including the dose in mg, expiry date, and batch number, mixed with lidocaine including the concentration, volume in ml, expiry date, and batch number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence documenting the subsequent injection of sodium chloride including the solution name, concentration, volume in ml, batch number, and expiry date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Sentence confirming the injected substance was accurately deposited in the anatomical site of injection and that the procedure was uneventful] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Include the anatomical site only if explicitly stated.)
Recommendation:
[Recommendation for relative rest, gradual return to activity, and avoidance of high-intensity physical stress on the affected body part for the advised duration] (Only include if a steroid injection was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit section entirely. Write each recommendation as a separate full sentence.)
[Recommendation for further investigations including MRI scan, X-ray, or nerve conduction study and the relevant body part for each] (Only include if no steroid injection was given and further investigations were explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence in the format "Following today's consultation, I recommend [investigations and body parts].")
[Recommendation for referral to physiotherapy colleagues including the name of the physiotherapy practice or location] (Only include if further physiotherapy was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write as a full sentence.)
[Recommendation for further specialist review specifying the relevant specialty such as orthopaedic, neurological, or sports physician review] (Only include if further specialist review was explicitly mentioned in the transcript, contextual notes, or clinical notes, else omit this line entirely. Write each recommendation as a separate full sentence in the format "I now recommend further [specialty] review.")
