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Physical Therapist
25-30 minutes

Initial Physical Therapy Evaluation

The s10.ai Physical Therapist Initial template is expertly crafted for physiotherapists to thoroughly document a patient's first visit. It encompasses sections for the history of present illness, signs and symptoms, pain evaluation, activity restrictions, and additional critical details. This template is perfect for capturing comprehensive information about a patient's condition and establishing specific, measurable objectives for their physical therapy path. It ensures all pertinent clinical data is meticulously recorded, aiding in effective treatment planning and progress monitoring. Ideal for physiotherapists aiming to enhance their documentation efficiency, this template leverages s10.ai's advanced AI scribe features.

3,983 uses
4.7/5.0
D
Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

History of Current Condition
[Detail in chronological order the patient's background and reason for seeking physical therapy]
[Explain the cause of the injury. Use “gradual onset” if no specific incident is identified]
Clinical Signs and Symptoms
[Use descriptive terms provided by the patient to characterize their pain. If they cannot describe it, note as “pain”]
Current Pain Level
[Indicate the patient's current pain level on a scale from 0 to 10]
[If no pain level is provided, classify it as mild, moderate, or severe]
Factors that Worsen or Alleviate Pain
Aggs: [List all activities that exacerbate the patient's pain][State as none if no activities worsen it]
Ease: [List all activities that alleviate the patient's pain][State as none if no activities improve it]
Activity Restrictions
[Identify any activities the patient is unable to perform due to their injury]
Co-existing Conditions/Complexities
[Document any co-existing conditions or diseases the patient has]
[State “none” if the patient has no co-existing conditions]
Previous Treatments / Surgeries
[Detail any treatments including injections, chiropractic care, other PT, or surgeries related to the current physical therapy visit]
[List all healthcare providers involved in this issue]
[State “None” if no treatments, surgeries, or other providers are involved]
Previous Imaging / Studies
[Summarize findings from any imaging studies such as x-ray, CT scan, MRI, fluoroscopy, etc.]
[State “none” if no imaging has been conducted]
Patient Goals
[Outline the patient's stated objectives for physical therapy]
OBJECTIVE
[Document all objective findings] (Organize logically with headers as needed)
Assessment:
[Compose an assessment paragraph summarizing the patient's history and objective findings.]
[Include the probable diagnosis (only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] [Explain why the patient would benefit from skilled physical therapy]
GOALS
[Write 5 functional physical therapy goals that are Specific, Measurable, Achievable, Relevant, and Time-bound, extending 6 weeks or longer. List them as bullets, not numbers.]
Plan:
- [Planned investigations (only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Planned treatment (only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
- [Other relevant actions such as counseling, referrals, etc. (only if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)]
Sample Clinical Note

Example of completed documentation using this template

History of Present Illness  
John Doe, a 45-year-old male, comes to physical therapy with complaints of lower back pain that started gradually three months ago. He mentions no specific incident that caused the pain.
Signs and Symptoms  
John describes his pain as a constant dull ache with occasional sharp twinges.
Pain at present  
John rates his current pain as 6 out of 10.
Aggravating and easing factors  
Aggs: Prolonged sitting, bending forward, and lifting heavy objects.  
Ease: Resting in a reclined position and applying heat.
Activity Limitations  
John is unable to perform his usual gardening activities and has difficulty sitting for extended periods at work.
Co-morbidities/Complexities  
Hypertension
Prior treatments / surgeries  
John has tried over-the-counter pain medications and chiropractic adjustments with minimal relief. He is not seeing any other providers for this issue.
Prior imaging /studies  
An MRI showed mild disc degeneration at L4-L5.
Goals  
John aims to return to his gardening activities and sit comfortably at work without pain.
OBJECTIVE  
- Posture: Slight forward head posture  
- Range of Motion: Limited lumbar flexion  
- Strength: Weakness in core muscles  
- Palpation: Tenderness over the lumbar paraspinals
Assessment:  
John Doe presents with chronic lower back pain likely due to mild disc degeneration at L4-L5. His symptoms and functional limitations suggest he would benefit from skilled physical therapy to improve core strength and flexibility, which will help alleviate pain and restore function.
GOALS  
- Improve lumbar flexion range of motion by 20 degrees within 8 weeks.  
- Increase core muscle strength to 4/5 on manual muscle testing within 10 weeks.  
- Sit comfortably for 2 hours without pain within 6 weeks.  
- Return to gardening activities for 30 minutes without pain within 12 weeks.  
- Reduce pain level to 3/10 during daily activities within 8 weeks.
Plan:  
- Initiate a core strengthening and flexibility program.  
- Educate on proper body mechanics and posture.  
- Plan for follow-up in 2 weeks to reassess progress.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "History of Present Illness" clinical template is an essential tool for healthcare professionals seeking to streamline patient evaluations in physical therapy. This comprehensive template guides clinicians through a detailed chronological report of the patient's condition, including the onset of injury, signs and symptoms, and current pain levels. It prompts the documentation of aggravating and easing factors, activity limitations, and any co-morbidities or complexities that may impact treatment. Additionally, it captures prior treatments, surgeries, and imaging studies, ensuring a holistic view of the patient's medical history. The template also facilitates the setting of patient-centered goals and includes sections for objective findings and assessments, which are crucial for developing a personalized treatment plan. By adopting this template, clinicians can enhance their documentation efficiency, improve patient care outcomes, and ensure a thorough and organized approach to physical therapy management.
Frequently Asked Questions

Common questions about this template and its usage

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