Physiotherapist-Vorlage
FF MSK INITIAL
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Are you a physiotherapist looking for a streamlined way to document your patient assessments and treatment plans? This 'FF MSK INITIAL' template is designed to help you create comprehensive and accurate clinical notes. It guides you through essential sections like subjective assessment, objective findings, analysis, and intervention plans. This template is perfect for physiotherapists to efficiently record patient information, track progress, and ensure clear communication. With this template, you can easily document all the necessary details of a patient's initial assessment, ensuring a thorough and well-organised record of their care.
Vorlagenvorschau
Patient Consent
Consent to Treatment and Information Sharing:
Consent given
Subjective Assessment:
Presenting Complaint: Lower back pain, radiating into the left leg.
History of Present Condition: Pain started 2 weeks ago after lifting a heavy box. Aggravating factors include prolonged sitting and bending. Easing factors include rest and lying down.
Pain Scale: 6/10 at worst, 3/10 at best.
Functional Impact: Difficulty with work (sitting at a desk), ADLs (putting on socks), and sports (unable to play football).
Red Flags Screening: No red flags identified.
Past Medical History: No relevant history.
Medications: Ibuprofen 400mg as needed.
Goals of Treatment: To reduce pain to 2/10 within 4 weeks, return to work duties, and be able to walk for 30 minutes without pain.
Objective Assessment:
Observation/Posture: Forward head posture, slight lateral shift to the right.
Active and Passive ROM: Lumbar flexion limited to 60 degrees, pain with left lateral flexion.
Strength Testing: Weakness noted in left hamstring (4/5).
Pain on Palpation: Tenderness over L4/L5 and left paraspinal muscles.
Special Tests: Positive Slump test on the left.
Neurological Screen: Sensation intact, reflexes 2+ bilaterally.
Functional Movement Tests: Pain with single leg stance on the left.
Analysis:
Analysis and Reasoning: Suspect lumbar discogenic pain with radicular symptoms. Possible nerve root irritation.
Plan and Intervention:
Education Provided: Advice on posture, body mechanics, and pain management strategies.
Intervention(s) Commenced: Manual therapy to lumbar spine and soft tissue release to paraspinal muscles. Exercises: nerve glides and core stability exercises. 30 minutes.
Home Exercise Programme: Nerve glides, core stability exercises, and postural correction exercises.
Referral Required: No referral required at this time.
Next Appointment Booked: Yes
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