Text Blaze for Physical Therapists

{note: color=none}Email type: {formmenu: Follow-up; Progress Update; Discharge; name=Email Type}

{endnote}Hi {formtext: name=name},

I hope you’re doing well. It was great seeing you on {formdate: MMM Do, YYYY; name=Appointment Date}.

{if: `Email Type` = "Follow-up"}Here’s a quick summary of your session and next steps:

Session Summary: {formparagraph: name=Session Summary}

Home Exercise Program: {formparagraph: name=Home Exercise Instructions}

Next Appointment: {formdate: MMM Do, YYYY; name=Next Appointment Date}{endif}{if: `Email Type` = "Progress Update"}I wanted to provide a quick update on your progress so far:

Progress Summary: {formparagraph: name=Progress Summary}

Next Steps: {formparagraph: name=Next Steps}{endif}{if: `Email Type` = "Discharge"}Congratulations on completing your physical therapy program!

Final Summary: {formparagraph: name=Final Summary}

Maintenance Recommendations: {formparagraph: name=Maintenance Recommendations}{endif}

If you have any questions or need to adjust your schedule, please don’t hesitate to reach out.

Best regards,

PAIN What amount of hip pain have you experienced the last week during the following activities?

1. Going up or down stairs: {formmenu: 0; 1; 2; 3; 4; name=stairs}
2. Walking on an uneven surface: {formmenu: 0; 1; 2; 3; 4; name=uneven}

FUNCTION, DAILY LIVING Please indicate the degree of difficulty you have experienced in the last week due to your hip.

1. Rising from sitting: {formmenu: 0; 1; 2; 3; 4; name=rising}
2. Bending to floor/pick up an object: {formmenu: 0; 1; 2; 3; 4; name=bending}
3. Lying in bed (turning over, maintaining hip position): {formmenu: 0; 1; 2; 3; 4; name=lying}
4. Sitting: {formmenu: 0; 1; 2; 3; 4; name=sitting}{raw_score=stairs + uneven + rising + bending + lying + sitting}

HOOS, Jr. Score: {=raw_score} / 24 {interval_lookup=[ 100.000,92.340,85.257,80.550,76.776,73.472,70.426,67.516,64.664,61.815, 58.930,55.985,52.965,49.858,46.652,43.335,39.902,36.363,32.735,29.009, 25.103,20.805,15.633,8.104,0.000 ]}

{if: isnumber(raw_score) and raw_score >= 0 and raw_score <= 24}{interval_score=interval_lookup[raw_score + 1]}Interval Score: {=interval_score; format=.3f} / 100{else}{error: Please ensure all questions are answered correctly (0–4 each).}{endif}

Interpretation: {if: interval_score >= 90}{error: Excellent hip health; type=success}{elseif: interval_score >= 70}{error: Good hip function; type=info}{elseif: interval_score >= 40}{error: Moderate impairment; type=warning}{else}{error: Severe hip disability}{endif}

Weight during last visit (lbs): {formtext: name=last weight; cols=12} {if: `last weight`=""}{error: Add weight} {elseif: `last weight` < 100 OR `last weight` > 300}{error: Check value}{endif}

Weight for today's visit (lbs): {formtext: name=today's weight; cols=12} {if: `today's weight` =""}{error: Add weight} {elseif: `today's weight` < 100 OR `today's weight` > 300}{error: Check value}{endif}

Difference (lbs): {=`last weight`- `today's weight`; format=,.2f}

{note}The example shown above works on this website.

{endnote}{note: insert=yes; color=none}Patient report: {formparagraph: cols=30; name=Patient report; default=Patient presents for follow-up visit reporting low back pain. States pain is localized to the lumbar region with occasional radiation into the bilateral lower extremities. Pain is aggravated by prolonged sitting, bending forward, and lifting activities. Reports some relief with rest and changing positions. Patient denies any recent trauma or injury.}

Primary concern: {formparagraph: cols=30; name=Primary concern; default=Low back pain limiting daily activities and work performance}

History of present condition: {formparagraph: cols=30; name=History of present condition; default=Patient reports gradual onset of low back pain approximately 3 months ago. Initially mild discomfort has progressively worsened over time. No specific injury recalled. Pain has been affecting ability to perform job duties and recreational activities.}

Patient goals: {formparagraph: name=Patient goals; cols=30; default=1. Reduce pain levels to allow return to full work duties 2. Improve lumbar range of motion and flexibility 3. Strengthen core musculature to prevent recurrence 4. Return to recreational activities without limitation}{endnote: trim=yes}{note: insert=yes; preview=no}{=`patient report`}{wait: delay=+.5s}{key: tab}{=`primary concern`}{wait: delay=+.5s}{key: tab}{=`history of present condition`}{wait: delay=+.5s}{key: tab}{wait: delay=+.5s}{key: tab}{wait: delay=+.5s}{key: tab}{wait: delay=+.5s}{key: tab}{=`patient goals`}{wait: delay=+.5s}{click: selector=.border.transition-colors}{endnote}

{note}The example shown above works on this website.

{endnote}{note: color=none} First name: {=split({site: text; page=https://scintillating-cannoli-486932.netlify.app/*; selector=header .font-semibold}, " ")[2]}

Last name: {=split({site: text; page=https://scintillating-cannoli-486932.netlify.app/*; selector=header .font-semibold}, " ")[1]}

Date of birth: {formtext: name=Date of birth}

External ID: {formtext: name=External ID}

SSN: {formtext: name=Social Security Number}

License/ID: {formtext: name=License/ID}

Billing notes: {formtext: name=Billing notes; cols=40}{endnote}{note: insert=yes; preview=no}{click: selector=[data-state="closed"]}{click: selector=:nth-child(1) > select}{key: downarrow}{key: enter}{key: tab}{=split({site: text; page=https://scintillating-cannoli-486932.netlify.app/; selector=header .font-semibold}, " ")[2]}{key: tab}{key: tab}{=split({site: text; page=https://scintillating-cannoli-486932.netlify.app/; selector=header .font-semibold}, " ")[1]}{key: tab}{key: tab}{=`date of birth`}{key: tab}{key: downarrow}{key: downarrow}{key: enter}{key: tab}{=`external id`}{key: tab}{=`social security number`}{key: tab}{=`license/id`}{key: tab}{key: downarrow}{key: downarrow}{key: enter}{key: tab}{=`billing notes`}{click: selector=.text-white.font-medium}{endnote}

Convert these rough notes into a properly structured SOAP note format.

Instructions:

• Transform unstructured notes into the standard SOAP format (Subjective, Objective, Assessment, Plan)
• Ensure all critical medical information is accurately categorized and retained
• Use clear, professional medical terminology and formatting
• Include relevant vital signs, symptoms, findings, and treatment plans in appropriate sections
• Maintain patient confidentiality by using appropriate clinical language

Sample Output:

SUBJECTIVE:

• Chief complaint: Chest pain x 2 days
• HPI: Substernal pressure-like pain, 6/10 intensity, worsens with exertion, improves with rest. Associated with mild SOB.
• PMH: HTN, hyperlipidemia, T2DM
• Medications: Lisinopril 10mg daily, metformin 1000mg BID, atorvastatin 20mg daily
• Social: Former smoker (quit 5 years ago), occasional ETOH
• Family: Father MI at 62

OBJECTIVE:

• Vital signs: BP 140/90, HR 88, RR 16, Temp 98.6°F, O2 sat 98% RA
• General: Well-appearing, NAD
• CV: RRR, no murmurs. No peripheral edema
• Pulm: CTA bilaterally
• EKG: NSR with minor ST depression V4-V6

ASSESSMENT:

• Chest pain, likely stable angina
• R/O acute coronary syndrome
• HTN, suboptimal control
• T2DM, stable

PLAN:

• Start metoprolol 25mg BID
• Order outpatient stress test within 1 week
• Labs: lipid panel, HbA1c
• Patient education on concerning chest pain symptoms
• Follow-up in 1 week for stress test results
• Consider aspirin 81mg daily pending stress test

You are a medical documentation specialist with expertise in transforming unstructured clinical notes into professional SOAP format. You help healthcare providers create accurate, compliant, and comprehensive patient records efficiently.

Your Task

Requirements

• Maintain 100% accuracy of all medical information provided
• Use appropriate medical terminology and standard abbreviations
• Ensure HIPAA-compliant language throughout
• Preserve all critical clinical details without omission
• Flag any unclear or potentially concerning information

SOAP Format Guidelines

SUBJECTIVE:

• Chief complaint with duration and context
• History of present illness (HPI): onset, location, duration, character, aggravating/alleviating factors, radiation, timing, severity
• Review of systems (ROS) pertinent positives and negatives
• Past medical/surgical history if relevant
• Current medications and allergies if mentioned
• Social history if clinically relevant

OBJECTIVE:

• Vital signs (specify which were obtained)
• Physical examination findings organized by system
• Laboratory/diagnostic results with reference ranges when available
• Mental status/general appearance

ASSESSMENT:

• Primary diagnosis with ICD-10 code if clearly indicated
• Differential diagnoses ranked by likelihood
• Clinical reasoning and confidence level for each diagnosis
• Risk stratification when applicable

PLAN:

• Immediate interventions and medications with specific dosing
• Diagnostic tests ordered with rationale
• Referrals with urgency level
• Follow-up timeline and specific instructions
• Patient education topics covered
• Return precautions and red flag symptoms

Sample output

SUBJECTIVE:

• Chief Complaint: "Sharp chest pain for 2 hours"
• HPI: 45-year-old male presents with sudden onset sharp, stabbing chest pain that began 2 hours ago while at rest. Pain is located left-sided, 8/10 severity, radiates to left arm. No alleviating factors identified. Denies SOB, nausea, or diaphoresis.
• ROS: Negative for fever, cough, palpitations. Positive for mild anxiety.
• PMH: HTN, hyperlipidemia
• Medications: Lisinopril 10mg daily, atorvastatin 20mg daily
• Allergies: NKDA

OBJECTIVE:

• Vitals: BP 150/95, HR 92, RR 18, O2 sat 98% RA, Temp 98.6°F
• General: Alert, anxious-appearing male in mild distress
• Cardiovascular: Regular rate and rhythm, no murmurs, no JVD
• Pulmonary: Clear to auscultation bilaterally
• ECG: Normal sinus rhythm, no ST changes

ASSESSMENT:

• Primary: Atypical chest pain, possible musculoskeletal etiology
• Differential: Rule out ACS, costochondritis, anxiety-related
• Low-moderate risk for cardiac event based on age and risk factors

PLAN:

• Immediate: Serial troponins q6h x3, continuous cardiac monitoring
• Diagnostics: CBC, BMP, lipid panel, chest X-ray
• Medications: Aspirin 325mg now, nitroglycerin SL PRN chest pain
• Follow-up: Cardiology consult if troponins elevated
• Patient education: Discussed signs of MI, when to seek immediate care
• Disposition: Observe in ED, discharge home if troponins negative

Summarize this data in a clear, professional format suitable for healthcare documentation.

Instructions

• Analyze the provided data for key medical information, trends, and significant findings
• Organize information by priority (critical findings first, then relevant details)
• Use clear, concise medical terminology appropriate for healthcare professionals
• Highlight any abnormal values, concerning trends, or actionable items
• Structure the summary in logical sections (e.g., vital signs, lab results, symptoms, etc.)

Expected Output

Clinical Data Summary:

Critical Findings:

• Most urgent or abnormal findings requiring immediate attention
• Values significantly outside normal ranges

Key Laboratory Data:

• Important lab values with reference ranges
• Trending patterns over time
• Clinical significance of results

Clinical Observations:

• Physical findings and symptoms
• Patient-reported concerns
• Observable changes or improvements

Assessment & Interpretation:

• Clinical significance of the data
• Correlation between different data points
• Overall patient status evaluation

Recommendations:

• Follow-up actions needed
• Additional testing requirements
• Treatment considerations

Act as a healthcare professional assistant for Physical Therapy. Based on the provided PT evaluation notes and objective findings, create a comprehensive Assessment (SOAP A) that includes a concise summary of findings, a clear PT diagnosis, justification for the treatment plan, and medical-necessity notes for any CPT codes used. Use professional medical terminology while maintaining clarity.

Instructions

• Analyze the provided PT notes and objective measurements to create a cohesive assessment
• Formulate an appropriate PT diagnosis based on the clinical findings presented
• Justify the proposed treatment plan with medical reasoning referencing specific findings
• Include medical necessity justification for recommended CPT codes
• Follow standard SOAP note formatting and medical documentation practices
• Ensure the assessment flows logically from findings to diagnosis to treatment rationale

Sample output

Generate a differential diagnosis for the following situation using the instructions and DOs and DON'Ts below.

Instructions

DOs & DON'TS