The s10.ai Physio Follow-up Assessment template is crafted for General Practitioners to efficiently document patient progress during physiotherapy sessions. This template meticulously records subjective reports of improvement, persistent symptoms, and objective findings from assessments such as Active Range of Motion (AROM) and palpation. It also provides detailed accounts of treatments administered, including manual therapy and prescribed exercises, while outlining future care plans. This structured format ensures thorough documentation, supporting effective patient management and continuity of care. Perfect for clinicians aiming to streamline their physiotherapy follow-up notes, this template significantly enhances clarity and efficiency in medical documentation.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Subjective//Verbal consent was obtained from the patient for the treatment session.The patient reports a 50% improvement in shoulder mobility since the last session. They find it easier to reach overhead but still experience difficulty with lifting heavy objects.Ongoing symptoms include intermittent shoulder pain lasting for about 30 minutes after lifting activities.Objective//AROM Assessment:- Shoulder flexion: 0-150 degrees, mild discomfort at end range- Shoulder extension: 0-40 degrees, no pain- Shoulder abduction: 0-120 degrees, moderate painPalpation Findings:- Tenderness over the anterior deltoid region- Mild stiffness in the upper trapeziusFunctional Tests:- Empty Can Test: Positive for painTreatment (Rx)//Manual Therapy:- Soft tissue mobilization on the upper trapezius, 5 minutes- Joint mobilization on the glenohumeral joint, Grade II, 3 sets of 30 secondsExercises:- Shoulder pendulum exercises: 3 sets of 10 repetitions- Wall slides: 3 sets of 15 repetitionsReassessments:- Improved shoulder flexion by 10 degrees post-treatment- Reduced pain during shoulder abductionAnalysis / Problem list//- Mechanical shoulder pain- Limited shoulder abduction- Functional limitation in overhead activitiesPlan//- Focus on improving shoulder ROM and strength- Home exercises:- Shoulder pendulum exercises: 3 sets of 10 repetitions daily- Wall slides: 3 sets of 15 repetitions daily- Theraband external rotation: 3 sets of 10 repetitions
Key advantages of using this template in clinical practice
Common questions about this template and its usage