Physiotherapist-Vorlage
Physio initial ax
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This Physiotherapy Initial Assessment template is designed for physiotherapists to document a patient's initial consultation. It covers subjective information like the presenting complaint, symptoms, and goals, as well as objective findings from observation and physical examination. The template also includes sections for assessment, treatment, and a plan for follow-up. This template helps streamline the documentation process, ensuring all essential information is captured efficiently. With Heidi, this template can be quickly populated from a clinical visit transcript, saving valuable time and improving the accuracy of your notes. This template was created on 1 November 2024.
Vorlagenvorschau
S – Subjective
Presenting complaint:
* Sharp pain in the right knee.
Mechanism of injury and date:
* Twisted knee while playing football, 28 October 2024.
Symptoms:
* Sharp pain on the inside of the right knee.
* Swelling around the knee joint.
* Difficulty weight-bearing.
Function (impact on life):
* Unable to walk without a limp and difficulty with daily activities.
Aggravating factors:
* Walking.
* Squatting.
* Twisting the knee.
Relieving factors:
* Rest.
* Ice.
* Elevation.
24-hour pattern:
* Pain is worse in the morning and after activity.
Activity:
- Regular activity:
* Plays football twice a week.
- Meeting guidelines (Y/N):
* N
- Training load (recent changes):
* Increased training load in the last month.
Health:
General health:
* Generally fit and healthy.
Past medical history, previous injuries and surgery:
* No significant past medical history.
* No previous injuries.
* No surgeries.
Family history:
* Father with osteoarthritis.
Usual GP:
* Dr. Smith.
Stress management:
* No specific stress management strategies.
Diet:
* Balanced diet.
Hours of sleep:
* 7-8 hours per night.
Imaging:
* No imaging performed yet.
Previous treatment:
* None.
Red flags:
* No red flags reported.
Social history:
* Lives with parents.
* Student.
Previous experiences with physiotherapy:
* None.
Patient goal for today:
* "To reduce pain and get back to playing football."
O – Objective
Observation:
* Swelling around the right knee.
* Mild bruising.
* Antalgic gait.
Palpation:
* Tenderness over the medial collateral ligament (MCL).
* No bony tenderness.
Range of motion (ROM):
* Reduced knee flexion (0-90 degrees).
* Painful knee extension.
Special tests:
* Positive valgus stress test at 30 degrees.
* Negative McMurray's test.
Strength and functional testing:
* Weakness with knee extension.
* Difficulty with single-leg stance.
A – Assessment
Impression:
Suspected Grade 2 MCL sprain.
Rx – Treatment
"Informed consent received from client for treatment."
"Discussed diagnosis, prognosis, contributing factors, and treatment plan."
Advice and education:
* RICE protocol (Rest, Ice, Compression, Elevation).
* Importance of early mobilisation.
* Gradual return to activity.
Activity recommendations:
* Avoid activities that aggravate pain.
* Progressive weight-bearing as tolerated.
Exercises prescribed:
* Quadriceps sets: 3 sets of 10 repetitions, 3 times a day.
* Hamstring curls: 3 sets of 10 repetitions, 3 times a day.
* Calf raises: 3 sets of 10 repetitions, 3 times a day.
* Straight leg raises: 3 sets of 10 repetitions, 3 times a day.
Manual therapy provided:
* Soft tissue massage to surrounding muscles.
Plan
* Review in one week.
* Provide home exercise program.
* Monitor progress and adjust treatment as needed.
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