Physiotherapist Template

Shoulder Assessment

A professional Physiotherapist template for healthcare professionals.

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Specialty

Physiotherapist

Used

29 times

Type

Note

Last edited

25/08/2025

Created by

Liam Dunphy

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About this template

Need a quick and comprehensive way to document your shoulder assessments? This 'Shoulder Assessment' template is perfect for physiotherapists. It guides you through a thorough examination, covering subjective findings, objective assessments, and treatment plans. This template ensures all key aspects of a shoulder examination are addressed, helping you create detailed and accurate clinical notes. With Heidi, this template can be quickly populated from your patient's visit transcript, saving you time and improving documentation accuracy.

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Subjective: VAS: 6/10 Aggravated by: Reaching overhead and sleeping on the right side. Eased by: Rest and ice. Social Hx: Patient is a builder and works full time. Mandatory Questions: Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, unilateral pain, no weight loss. Dizziness/Vertigo/Drop attacks/Nausea: Denies. Dysphasia/Dysarthria/Swallow/Oro-facial: Denies. Vision/Diplopia/Nystagmus: Denies. Increased sweating/Night sweats: Denies. Power loss/Numbness/Pins & needles: Reports some numbness in the hand. Headaches/Migraine: Denies. Prolonged steroids/Osteoporosis: Denies. Anti-coagulants: Denies. Sleep disturbance: Reports difficulty sleeping due to pain. Cough/Sneeze: Denies. Metal Implants: Denies. Scans/X-rays: X-rays taken 2 weeks ago showed mild AC joint arthrosis. Past Medical History/Previous Injury: No previous shoulder injuries. Patient had a fractured wrist 5 years ago. Patient Valued Outcome: Patient wants to return to work without pain. Objective Assessment: Posture: Forward head posture, rounded shoulders. Movements: Painful active and passive range of motion in abduction and external rotation. Impingement Tests: Positive Neer's and Hawkins-Kennedy tests. Capsular Tests: Limited external rotation. Scapular Control: Scapular dyskinesis noted. AC Joint Tests: Positive AC joint compression test. 1st Rib: Negative. SC Joint: Negative. Palpation: Tenderness over the supraspinatus tendon and AC joint. Neck: No referred pain from the neck. ULTTs: Negative. Thoracic: No thoracic involvement. Elbow: No elbow involvement. Other: No other findings. IMPRESSION: Right shoulder impingement syndrome with AC joint arthrosis. PLAN: Advise on activity modification, ice, and pain relief. Commence with shoulder rehabilitation exercises. TREATMENT: Soft tissue massage to the shoulder muscles. Shoulder mobilisations. Education on posture. Home Exercise Programme: Pendulum exercises, scapular retractions, and external rotation exercises. Advice given: Advised on activity modification, ice application, and posture correction. Plan for Next Day: Review patient's progress and adjust the treatment plan as needed. Provide further education on home exercises.