Physiotherapist Note
• Pain – R Shoulder ↓ (2/10)
• Reason – Improved ROM, reduced inflammation post-mobilisation.
• Post-session soreness – Mild, delayed onset, resolved within 24 hrs.
• Aggs – Overhead lifting, sudden movements
• Eases – Rest, ice, gentle stretching
• HEP – 3x/day, 80% compliance, focus on external rotation.
• New – Occasional paresthesia into hand with sustained overhead activity.
• Hands-on – GHJ mobilisations (Grade III, 10 mins), Scapular STR (5 mins).
• Exercises / Exercise therapy – Pendulums, external rotation with theraband, scapular retraction.
• Outcome / Clinical response – Significant reduction in pain during active flexion, increased ER ROM by 15 degrees.
• Future Plan – Review in 1 week. Continue HEP. Progress theraband resistance. Commence gentle strengthening for rotator cuff.
• Pain – [Body part and side (L/R/bilateral) with direction indicator (↑ ↓ same variable)](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• Reason – [Clinical reason for pain change or status](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• Post-session soreness – [Soreness experienced after the previous treatment session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• Aggs – [Aggravating factors listed on one line, separated by commas](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• Eases – [Easing factors listed on one line, separated by commas](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• HEP – [Home exercise programme compliance or status](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand such as 2x/day. Do not use full sentences or direct patient quotes.)
• New – [Any new symptoms, issues, or developments](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and clinical shorthand. Do not use full sentences or direct patient quotes.)
• Hands-on – [Manual therapy techniques applied and duration in minutes, or "none today"](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements and common clinical abbreviations such as mins, STR, GHJ. Do not use full sentences or direct patient quotes.)
• Exercises / Exercise therapy – [All exercises listed on one line, separated by commas](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements. Do not use full sentences or direct patient quotes.)
• Outcome / Clinical response – [Patient response to treatment during the session](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief statements. Do not use full sentences or direct patient quotes.)
• Future Plan – [Timeframe, frequency, progression strategy, or review timing](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else state "Not reported". Use brief concise statements and common abbreviations such as 2x/day and 3x12, and symbols such as ≤. Do not use full sentences or direct patient quotes.)