Physiotherapist-Vorlage
Physiotherapy note (custom)
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a comprehensive **physical therapy documentation** solution? This template is designed for physiotherapists to create detailed clinical notes. It covers all key areas, from patient history and goals to objective findings, assessment, treatment, and plan. This template helps physiotherapists to efficiently document patient progress and treatment plans. With Heidi, the AI scribe, this template can be quickly populated from your patient consultations, saving you time and improving the accuracy of your notes.
Vorlagenvorschau
Current Condition/Complaint:
- Right shoulder pain and limited range of motion.
- Onset 15 October 2024.
- Patient reports pain started after lifting a heavy box at work.
- No prior therapy or surgery.
- Pain has gradually worsened over the past two weeks.
Social History:
- Works as a warehouse operative, physically demanding job.
- Exercises 3 times per week.
Medical History:
- No known medical conditions.
- No previous surgeries.
- No known allergies.
- Medications: None.
- Non-smoker, drinks alcohol occasionally.
- Family history of osteoarthritis.
Patient Goals:
- Short-term: Reduce pain and improve shoulder range of motion within 4 weeks.
- Long-term: Return to full work duties without pain within 3 months.
Subjective:
- Patient reports a sharp pain in the right shoulder, radiating down the arm. Pain is worse with overhead activities and at night. Reports a pain score of 7/10.
- Patient is able to perform activities of daily living with some difficulty.
- No prior treatment.
- No information from family or caregivers.
Objective:
- Observation: Patient guarding right shoulder.
- Range of motion: Limited shoulder flexion, abduction, and internal rotation. Painful arc noted.
- Strength testing: Weakness in shoulder abduction and external rotation.
Assessment:
- Right shoulder impingement syndrome.
- Prioritized problems: Pain, limited range of motion, weakness.
- No progress towards stated goals at this time.
- Plan will be modified if no improvement is seen in 2 weeks.
Treatment:
- Manual Therapy: Soft tissue mobilisation to the shoulder muscles.
- Exercise Therapy: Range of motion exercises, strengthening exercises (rotator cuff).
- In clinic: Ultrasound therapy.
- Home exercise programme: Patient instructed on home exercises.
- Education strategies for the patient: Advice on activity modification.
Plan:
- Treatment plan: 2 sessions per week for 4 weeks, including manual therapy, exercise therapy, and ultrasound. Re-assessment in 2 weeks.
- Anticipated goals: Reduction in pain, improved range of motion, and improved strength.
- No referrals needed.
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