Breast Surgery Post OP Return Visit

A professional Physiotherapist template for healthcare professionals.

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Specialty

Physiotherapist

Used

9 times

Type

Note

Last edited

9/12/2024

Created by

Anonymous

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About this template

This oncology physical therapy progress note template is designed for physiotherapists managing post-operative care for breast surgery patients. It includes sections for documenting treatment time, manual therapy, therapeutic exercises, and patient responses. The template also covers pain assessment, circumferential measurements, and integumentary system findings. Ideal for tracking patient progress and ensuring comprehensive care, this template is optimized for use with Heidi, the AI medical scribe, to streamline documentation and enhance patient outcomes. Perfect for physiotherapists seeking efficient and thorough documentation solutions.

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Oncology physical therapy progress/treatment note Name: Jane Doe Visit date: 2023-10-15 MRN: 123456 Visit number: 3 Total treatment time: 60 mins Re-evaluation 97164 Manual therapy 97140 15 mins Therapeutic exercise 97110 20 mins Neuromuscular re-education 97112 10 mins Gait training 97116 15 mins PBM 10 mins Chief complaint: Post-operative pain and limited range of motion in the right shoulder Patient comments: "I feel some improvement, but the pain is still there, especially when I try to lift my arm." Response to treatment: Patient reports mild improvement in pain and increased range of motion. HEP compliance: Patient reports 80% compliance with the home exercise program. Examination/clinical findings Pain Present: 5/10 Best: 3/10 Max: 7/10 Location: Right shoulder Characteristic: Dull ache with occasional sharp pain Sensation: Normal sensation in the right upper extremity Circumferential measurements Baseline: 2023-09-01 Dominant hand: Right Right 2023-09-01 2023-09-15 2023-10-01 2023-10-15 Shoulder 40 cm 39 cm 38 cm 37 cm Elbow 30 cm 29 cm 29 cm 28 cm Wrist 18 cm 18 cm 17 cm 17 cm Non-dominant hand: Left Left 2023-09-01 2023-09-15 2023-10-01 2023-10-15 Shoulder 39 cm 39 cm 39 cm 39 cm Elbow 29 cm 29 cm 29 cm 29 cm Wrist 17 cm 17 cm 17 cm 17 cm Lymphedema measurement findings: No significant lymphedema noted Lymphedema signs/symptoms: None Edema findings: Mild edema in the right shoulder Integumentary system: Scars Well-healed surgical scar on the right shoulder Edema Mild edema present Ecchymosis None Erythema None Integrity Skin intact ROM: 2023-09-01 ROM: 2023-10-15 ROM comments: Improved range of motion in the right shoulder since the last visit Skilled services provided Manual therapy: Soft tissue mobilization and joint mobilization techniques applied to the right shoulder Therapeutic exercise: Shoulder flexion and abduction exercises, resistance band exercises Treatment duration: 4 weeks to right shoulder Assessment: Patient is progressing well with therapy, showing improvement in pain levels and range of motion. Additional communications: Discussed progress with the patient and encouraged continued compliance with the home exercise program. Plan: Continue with current treatment plan, reassess in 2 weeks.