Physiotherapist-Vorlage
Physio Work Cover Initial
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This 'Physio Work Cover Initial' template is designed for physiotherapists to document initial assessments for patients with work-related injuries. It includes sections for history of presenting condition, radiology findings, past medical history, employment details, social history, goals, objective findings, treatment provided, assessment, and plan. This template ensures comprehensive documentation, aiding in effective treatment planning and communication with other healthcare providers. Ideal for physiotherapists handling work cover cases, it helps streamline the documentation process, ensuring all relevant information is captured accurately.
Vorlagenvorschau
HOPC
- Patient presents with lower back pain following a lifting injury at work on 01/09/2023.
- Pain is aggravated by prolonged sitting and eased by lying down.
- Pain is described as a constant dull ache with occasional sharp pains during movement.
Radiology:
- MRI scan on 05/09/2023 showed a herniated disc at L4-L5.
Past Medical History
- Hypertension, managed with Amlodipine 5mg QD.
- No known allergies.
Employment
- Occupation: Warehouse Worker
- Company Name: ABC Logistics, Logistics Industry
- Regular hours: 40hrs a week
- Duties: Heavy lifting, loading and unloading goods, physically demanding
- Current work capacity certificate: GP certified for light duties only
- Case Manager: John Smith
- On modified hours: Yes, currently working 20hrs a week
- On Modified duties: Yes, restricted to light duties such as inventory management
- Return to work plan in place: Yes, see files
Social History
- Non-smoker, occasional alcohol use
- Lives with spouse and two children
- No relevant family medical history
Goals
- Short-term: Reduce pain and improve mobility within 4 weeks
- Long-term: Return to full duties at work within 12 weeks
Objective
- Active range of motion: Limited flexion and extension in lumbar spine
- Palpation: Tenderness over L4-L5 region
- Strength: Reduced strength in lower back muscles
Treatment
- Pain science education provided
- Mobilisation: Gr II PA R) L4/5 2x30secs
- Unilateral soft tissue massage upper L) calf
- Active therapy: 3x10 Single leg calf raises, 3x10 L) ankle knee to walls
- Home exercise program: 3x10 bridges, 3x10 pelvic tilts, 3x/day
Assessment
- Diagnosis: Herniated disc at L4-L5 causing lower back pain
- Differential Diagnosis: Lumbar strain
- Progress: Patient shows slight improvement in pain levels
- Barriers: Limited adherence to home exercise program
Plan:
- Continue current treatment plan
- r/v 2/52
- Likely therapy: Progress to more advanced strengthening exercises
- Referrals: None needed at this time
- Communication: Will send progress report to GP before next session
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