Physiotherapist-Vorlage
LW Follow UP
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document your physiotherapy sessions? This LW Follow Up template is designed for physiotherapists to efficiently record patient progress. It helps you capture essential information like symptom updates, rehab progress, patient goals, and physical examination findings. With Heidi, this template can be quickly populated from your session transcript, saving you time and ensuring accurate documentation. This template is perfect for creating detailed and compliant physical therapy documentation examples.
Vorlagenvorschau
**Brief Summary:**
- Patient presents with ongoing right shoulder pain and limited range of motion following a fall two weeks ago. Currently undergoing physiotherapy to improve mobility and reduce pain.
- Patient reports slight improvement in pain levels since the last session, but range of motion remains limited.
- Continue with current treatment plan, reassess progress in two weeks.
"Clinical entry generated with Heidi AI medical notetaking software. Patient verbal consent obtained for recording at commencement of session or in prior session. Edits/corrections made manually after automatic clinical notes generation."
**Update on Patient Symptoms / Recent History:**
- Patient reports a sharp increase in pain after attempting to lift a heavy object yesterday. Pain is now radiating down the arm.
- Patient has been resting the arm and using ice as instructed.
**Rehab Since Last Review:**
- Tolerating exercises well, performing them daily.
- Exercises performed daily as instructed.
- Compliant with previous instructions.
- Patient expressed concern about the recent increase in pain.
- Patient reported a slight improvement in pain levels before the recent flare-up.
- Patient feels the exercises were helping to improve range of motion before the recent increase in pain.
**Patient Goals / Expectations:**
- Patient aims to regain full range of motion and return to pre-injury activity levels.
**Relevant Social History:**
- Patient is a construction worker and needs to return to work as soon as possible.
**Physical Examination:**
- Range of motion: Shoulder flexion limited to 90 degrees, abduction limited to 80 degrees.
- Strength: Weakness noted in shoulder abduction (3/5).
- Palpation: Tenderness over the supraspinatus tendon.
- * * * * * Neer's test positive.
**Ongoing / Updated Diagnostic Impression:**
- Suspected rotator cuff tendinopathy with possible impingement.
**Treatment / Intervention:**
- Manual therapy to the shoulder joint.
- Soft tissue massage to the surrounding muscles.
- Instruction in pain management techniques.
**Reassessment Findings (Post-Treatment):**
- Patient reports a slight reduction in pain after treatment.
- * * * * * Neer's test remains positive.
**Advice / Exercises:**
- Continue with home exercises, including pendulum swings and gentle range of motion exercises.
- Avoid activities that exacerbate pain.
- Apply ice for 15-20 minutes, 3-4 times per day.
**Plan:**
- Schedule a follow-up appointment in two weeks.
- Review progress and adjust treatment plan as needed.
- Discuss the possibility of further imaging if symptoms do not improve.
**Additional Notes:**
- Patient was advised to contact the clinic if pain worsens significantly.
**Dictated Letter:**
"transcribe the following verbatim"
Patient is advised to rest and avoid aggravating activities. Further review in two weeks.
"end of dictation"
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