Physiotherapist-Vorlage
Ankle Ax
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document your physiotherapy sessions? This Ankle Ax template is designed for physiotherapists to efficiently record patient assessments and treatment plans. It covers subjective findings, objective assessments like range of motion and strength, and outlines the plan for the patient's care. This template helps you to create detailed notes, ensuring all key aspects of the patient's condition and treatment are captured. With Heidi, this template can be quickly populated from your session transcript, saving you time and improving the accuracy of your clinical documentation. This template was last updated on 1 November 2024.
Vorlagenvorschau
Subjective:
Patient presents today with ongoing pain in their left ankle, sustained during a netball game three weeks ago. The patient reports a twisting mechanism of injury. They have been following the home exercise program (HEP) and are reporting a gradual improvement in pain levels, currently rating it as a 3/10 at rest and 5/10 during activity. They report that they are able to walk without a limp, but still experience some stiffness in the mornings.
Patient valued outcomes (PVOs):
The patient's goals are to return to playing netball at their previous level of performance and to be able to run and jump without pain.
Objective Assessment:
Palpation: Tenderness to palpation over the anterior talofibular ligament (ATFL) and the lateral malleolus. No significant swelling noted.
ROM (Range of Motion): Ankle dorsiflexion: 10 degrees (reduced compared to the unaffected side). Ankle plantarflexion: 45 degrees. Inversion and eversion are within normal limits.
Strength: Pain-free strength in all directions. Slight weakness noted with resisted ankle inversion.
Proprioception: Reduced proprioception noted on the left ankle compared to the right.
Gait: Normal gait pattern observed.
Squat: Able to perform a single-leg squat on the right leg, but unable to do so on the left leg due to pain and instability.
IMPRESSION:
Left ankle sprain, likely grade 1-2. Reduced range of motion and proprioception. Patient is making good progress with current management.
PLAN:
Continue with current HEP. Progress exercises as tolerated. Review in one week.
TREATMENT:
Manual therapy to the ankle joint to improve range of motion. Proprioceptive exercises using a wobble board.
HEP (Home Exercise Programme):
Continue with ankle range of motion exercises (dorsiflexion, plantarflexion, inversion, eversion). Progress to single-leg balance exercises. Begin with 30 seconds holds, 3 times a day.
ADVICE:
Continue to ice the ankle after activity. Avoid activities that provoke pain. Gradually increase activity levels as tolerated.
NEXT DAY:
Continue with current management plan.
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