Physiotherapist Template

Physio Initial Inpatient

A professional Physiotherapist template for healthcare professionals.

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Specialty

Physiotherapist

Used

35 times

Type

Note

Last edited

8/7/2025

Created by

Hugo Henderson

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About this template

This 'Physio Initial Inpatient' template is designed for physiotherapists working in acute hospital settings. It helps document the initial assessment and treatment plan for patients referred to physiotherapy due to functional decline, often secondary to a primary illness. The template includes sections for reason for referral, history of present condition, past medical history, social history, objective findings, mobility assessment, treatment provided, assessment, and plan. This comprehensive template ensures all relevant information is captured, facilitating effective patient care and communication among the healthcare team. Ideal for physiotherapists, this template streamlines documentation and enhances patient management.

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Reason for referral: Functional decline post viral illness HOPC: - Patient admitted due to severe respiratory distress following a viral infection. - Requires physiotherapy for mobility improvement and respiratory function enhancement. - Complains of worsening leg pain and persistent headache. Medications: See med chart PMHx: - History of chronic obstructive pulmonary disease (COPD) - Previous episodes of pneumonia SH: - Lives in a single-story house with spouse - Previously independent in mobility and daily activities - Exercise tolerance was moderate, could walk 500 meters without rest - Receives cleaning services twice a week and meals on wheels five times a week - No falls in the past 12 months Objective: - Found resting in bed, alert and oriented, saturating comfortably on 2L O2 via nasal prongs - Vitals observations: Between the flags (BTF) - Attachments: IV line in situ - Auscultation: Decreased breath sounds in lower left zone, with inspiratory crackles and expiratory wheeze - Lateral Basal Expansion (LBE): Reduced on the left side - Cough: Strong, dry, non-productive, and effective - CXR: Bilateral infiltrates consistent with viral pneumonia Mobility: - Supine: Independent - Sit Bal: 1x assist with strong lean to right - STS: Independent with use of rail - Stand Bal: 1x moderate assist (MA) - Transfer: 2x moderate assist (MA) with roller frame (RF) - Walking: 1x light assist (LA) 10m limited by shortness of breath (SOB) Treatment: - Education on risks of prolonged bed rest - Active Cycle of Breathing Techniques (ACBT) x2 rounds - Mobilized 2x8m with assistance Assessment: - Nurses should assist patient with transfers and mobilization on the ward - Patient is not at baseline function - Patient is not safe for discharge from physiotherapy due to limited mobility and respiratory issues - Barriers: 12 stairs at home with no rails and minimal support to assist Plan: - Recommend continued respiratory physiotherapy and mobility exercises - Next physiotherapy review in 2 days - Goal: Improve walking distance and respiratory function