Physical Therapy Note Template

History of Present Injury

(only include the following if mentioned in the transcript, don’t include the item if not specified) [Location of pain: Patient reports [e.g., pain, discomfort, stiffness, limited mobility] in [specific body part, e.g., right shoulder].] [Pain rating: [e.g., 6/10] on a scale of 0-10.] [Onset: [e.g., Gradual/sudden onset after [e.g., lifting a heavy object, sports activity].] [Duration: [e.g., Ongoing for [e.g., 2 weeks].] [Aggravating factors: [e.g., Overhead movements, lifting, prolonged sitting].] [Alleviating factors: [e.g., Rest, ice, OTC pain medications].] [Previous treatments: [e.g., None, NSAIDs, rest, prior physical therapy].]

Chief Complaint

Physical Therapy Note Template

Physical Examination/Objective Assessment

(only include the following if mentioned in the transcript, using following structure and list in point form) Observation: [observation]. Palpation: [palpation]. Range of Motion (ROM): [ROM]. Strength Testing: [strength testing]. Special Tests: [special tests].

Problem

[Provide very brief summary of physiotherapy diagnosis if possible]

Treatment

[List all treatments performed during the encounter in the clinic, in the past tense using following structure: [Education provided regarding diagnosis] [General physiotherapy advice] [Physiotherapy treatment performed during the appointment (Dry Needling, Massage, Manual Therapy)] [Exercise Prescription (Details of Technique, Dosage prescribed, Specific Education re Dosage if appropriate) ]

Plan/Exercise Prescription

[List plans and physiotherapy recommendations for the future, in the future tense, any prescribed exercises, education, physiotherapy advice in details and in point-form]