Effective clinical documentation is essential for osteopaths when assessing and managing pelvic health conditions. Accurate and structured documentation not only supports patient care but also ensures compliance with medical standards. This guide will walk you through the process of creating and formatting pelvic health assessments using a comprehensive template, enhancing your ability to deliver quality care.

Reason for Consultation

Begin by clearly stating the reason for consultation. For example, "Postpartum pelvic pain and urinary incontinence" provides a concise description of the patient's concerns, setting the stage for detailed documentation.

Relevant Medical History

Include any pertinent medical history, such as "History of gestational diabetes," to highlight factors that may influence the patient's current condition and treatment plan.

Obstetric History

Detail the labour and delivery history to understand potential impacts on pelvic health. For instance, "Vaginal delivery, 8 hours of labor" and "Episiotomy performed" provide critical context for postpartum recovery.

Current Symptoms

Document current symptoms meticulously, covering aspects like urinary symptoms ("Stress incontinence"), urinary habits ("Frequent urination"), and voiding patterns ("Normal"). This comprehensive approach ensures no symptom is overlooked.

Bowel Habits

Record bowel habits, including frequency and consistency of bowel movements ("Daily, soft") and any abdominal discomfort ("Occasional bloating"). Understanding these factors can inform treatment strategies.

Diet and Lifestyle

Assess dietary habits ("Balanced diet"), fluid intake ("2 liters per day"), and lifestyle choices, as these can significantly impact pelvic health and recovery.

Sexual Health

Explore sexual health status, discomfort levels ("Mild discomfort"), and psychological factors ("Anxiety about pain"), as they can influence the patient's overall well-being and treatment outcomes.

Mental Health

Consider the patient's mental health, mood, and support system, such as "Generally positive" mood and "Strong family support," to provide holistic care.

Physical Activity

Discuss exercise goals and previous experiences, like "Interested in yoga and pilates," to tailor physical activity recommendations that support recovery.

Examination Findings

Include findings from physical examinations, such as "Slight anterior pelvic tilt" and "2-finger width separation" for diastasis recti, to guide treatment planning.

Management Plan

Formulate a management plan that addresses key areas such as pelvic floor exercises ("Kegel exercises"), sexual health ("Gradual resumption"), and lifestyle modifications ("Increase fiber intake"). Provide clear guidelines for each component to facilitate patient adherence and recovery.

Follow-up and Referrals

Outline follow-up appointments ("6 weeks") and any necessary referrals, like to a physiotherapist, to ensure continuous care and support.

Osteopaths can significantly enhance their documentation process by integrating AI medical scribes like Notis AI Medical Scribe. This advanced tool reduces the time spent on documentation by automating the transcription of patient interactions into structured SOAP notes. For specialists in pelvic health, this technology offers numerous benefits:

Time Efficiency and Ease of Use

Notis reduces documentation time by up to 80%, allowing osteopaths to focus more on patient care. Its integration into WhatsApp ensures a seamless user experience without the need for additional software.

High Accuracy and Comprehensive Documentation

With a transcription accuracy of 99%, Notis ensures reliable medical notes that maintain high professional standards. Its ability to instantly generate structured SOAP notes streamlines the documentation process, making it an invaluable tool for osteopaths.

Utilizing AI medical scribes like Notis not only enhances productivity but also improves the accuracy and completeness of clinical notes. By embracing these technologies, osteopaths can dedicate more time to patient care, ultimately enhancing outcomes and satisfaction.