| Patient details and consultation date | Patient name, date and session type are captured automatically from Cliniko and written into every note header. | Header |
| Presenting complaint and symptoms | The AI extracts the patient's presenting complaint, pain location, onset, duration and character from your spoken consultation notes. | Subjective |
| Relevant history — past medical, family, social and medication | Relevant history is drawn out from the consultation recording and structured into the Subjective section with separate sub-fields for history and medications. | Subjective |
| Clinical findings — examination, palpation, movement tests | Objective findings from your examination are structured under the Objective section, including range of motion, special tests, palpation findings and postural observations. | Objective |
| Working diagnosis and clinical reasoning | The Assessment section captures your working clinical reasoning and differential considerations, with relevant research references. The clinician reviews and approves all reasoning before saving. | Assessment |
| Red flag screening | The AI highlights any red flag indicators mentioned during the consultation and prompts you to document whether each was considered and how it was managed. Red flags are never dismissed automatically — the clinician must confirm. | Assessment |
| Treatment given | The Plan / Treatment section documents techniques used, areas treated and clinical decisions made during the session. | Plan |
| Advice given to the patient | Advice given — including lifestyle, activity modifications and home management — is extracted from the consultation and included in the Plan section. | Plan |
| Exercise prescription | Home exercises prescribed are documented in the note and, with RehabRx, a full programme with video demonstrations is emailed to the patient. | Plan |
| Plan and follow-up arrangements | Follow-up timing, referral decisions and management plan are included at the close of the Plan section. | Plan |
| Patient consent | The consent modal is displayed and confirmed before recording begins. Consent confirmation is timestamped and logged against the session. | Consent |