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Physical Therapist
5-10 minutes

Physical Therapy Progress Note

The s10.ai Physio Progress Note template is a vital resource for physiotherapists aiming to meticulously document patient progress throughout treatment. This template facilitates comprehensive recording of patient history, objective findings, assessments, and treatment plans, capturing the intricacies of physical therapy sessions with precision. It includes specific measurements, test results, and patient education strategies, ensuring thorough documentation that enhances patient care and fosters seamless communication with other healthcare professionals. Perfect for monitoring progress in conditions like back pain, sports injuries, and post-surgical rehabilitation, this template empowers physiotherapists to deliver superior patient outcomes. Explore the s10.ai Physio Progress Note template to elevate your clinical documentation and patient management.

1,630 uses
4.2/5.0
J
Jordan Blake
Template Structure

Organized sections for comprehensive clinical documentation

History of Current Condition (paragraph format)
[Comprehensive account of main injury, issue, complaint, or symptom]. [Explanation of how the injury happened or complaint started (mention only if applicable and available)]. [Describe the development of the complaint and nature of symptoms (mention only if applicable and available)]. [Detailed narrative of the patient's self-report of their current status, symptoms, reason for visit etc (if available)]. [Patient's activity level, disability, social history (mention only if applicable and available)]. [Goals and prior response to treatment intervention (mention only if applicable and available)]
Objective (organized by category):
[Physical examination details (if applicable and available)] [Observations, tests, and measurements by the therapist (if applicable and available)] [Specific measurements and assessment findings (if applicable and available)] [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [Investigations with results]
Assessment (paragraph format):
[Therapist's professional opinion based on subjective and objective findings (if applicable and available)]. [Progress or changes in objective or subjective measures (if applicable)]. [Factors affecting progress and any need for modification in the plan (if applicable)]. [Referrals to other professionals (mention only if applicable and available)]. [Response to treatment and exercises (if applicable)]. [Education strategies for the patient (mention only if applicable and available)]. [Equipment required and its usage (mention only if applicable and available)]. "Patient will continue to benefit from skilled physical therapy to address aforementioned impairments and limitations to return to their activities of choice."
Charges (bullet points):
- [Treatment plan including interventions, frequency, and duration (if available)]
Patient educated/counseled on:
- [Patient education provided in short bullet points]
Sample Clinical Note

Example of completed documentation using this template

History of Present Condition:
The patient, a 45-year-old male, reports experiencing lower back pain that started after lifting a heavy object at work two weeks prior. The pain has progressively intensified, extending to the left leg, and is characterized as a sharp, shooting sensation. The patient notes difficulty in performing daily tasks and has a history of a sedentary lifestyle. His objective is to return to work and engage in normal activities without discomfort. Previous physiotherapy sessions have offered temporary relief.
Objective:
Physical examination shows tenderness in the lumbar area with a restricted range of motion in the lower back. Observations include a positive straight leg raise test on the left side. Specific measurements indicate decreased lumbar flexion and extension. Blood pressure is 120/80 mmHg. No findings from a mental state examination were noted. MRI results reveal a herniated disc at L4-L5.
Assessment:
Based on the subjective and objective findings, the therapist determines that the patient is experiencing lumbar radiculopathy due to a herniated disc. There has been minimal progress in alleviating pain, requiring a modification in the treatment plan. Referral to an orthopedic specialist is advised. The patient has responded positively to initial exercises focusing on core strengthening. Educational strategies include teaching proper lifting techniques and posture correction. The patient needs a lumbar support belt for daily use. The patient will continue to benefit from skilled physical therapy to address the aforementioned impairments and limitations to return to their preferred activities.
Charges:
- The treatment plan includes manual therapy, core strengthening exercises, and postural training, with sessions twice a week for six weeks.
Pt educated/counseled on:
- Proper lifting techniques
- Importance of regular exercise
- Posture correction
- Use of lumbar support belt
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "History of Present Condition" clinical template is an essential tool for healthcare professionals seeking to document patient encounters with precision and clarity. This comprehensive template allows clinicians to capture a detailed narrative of the primary injury, problem, or symptom, including its onset, progression, and the patient's self-reported status. It also facilitates the recording of the patient's activity level, social history, and treatment goals. The "Objective" section is meticulously organized by category, enabling the documentation of physical examination details, observations, tests, and specific assessment findings. The "Assessment" section provides a structured format for therapists to articulate their professional opinion, track progress, and identify factors affecting treatment. It also supports the inclusion of referrals, patient education strategies, and equipment needs. The "Charges" section outlines the treatment plan, while the "Pt educated/counseled on" section ensures that patient education is succinctly documented. By adopting this template, clinicians can enhance the accuracy and efficiency of their clinical documentation, ultimately improving patient care and outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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Physical Therapy Progress Note