This physiotherapy assessment template provides a structured note format appropriate for patients presenting with musculoskeletal conditions. It includes sections for the history of presenting complaint, radiology findings, comprehensive history, treatment, assessment, and plan. Both physiotherapists and physical therapists may use this template. With the use of Heidi’s AI, this template can:
Automatically generate notes while allowing physiotherapists to focus on their hands-on patient interactions
Provide clear and comprehensive assessments for effective continuity of care
Make an outline of the patient’s overall assessment, goals, management, and follow-up instructions
A physiotherapy assessment is a comprehensive clinical evaluation that documents a patient’s physical condition, functional limitations, and subjective experiences. This holistic assessment serves as the foundation for developing personalized treatment goals and creating an evidence-based recovery plan.
The specifics of each physiotherapy assessment depend on the individual patient and practice area. However, most involve a detailed examination of the patient’s movement patterns, strength, flexibility, pain, and functional limitations. Documenting a physiotherapy assessment can be very time-consuming and cognitively taxing, so clinicians often use a template to streamline the process.
In this article, we’ll discuss the benefits of using a physiotherapy assessment template and explore special considerations for specific patient groups. We also provide an example physiotherapy assessment, followed by explaining how AI-enabled templates can make your workflow more efficient.
The Impact of Good Physiotherapy Assessment Templates
Physical therapy, while primarily used for recovery from illness or injury, is also used for improving one’s health and mobility. It’s all about constant progress and consistent follow-ups to achieve improved functionality. Because of that, every session needs to be tracked to know whether the management is helping improve the patient’s condition or not.
Without a good, standardised physiotherapy assessment template, it would be hard to monitor the improvement of the patient. But with a consistent template, it’s easy to analyze patterns and identify the root cause of the condition, barriers to progress, attitudes towards management, and the individual needs of each patient.
A challenge physiotherapists face, however, is that therapy sessions can lack patient-centered communication. In the hands-on nature of physiotherapy, it's common to alternate between examining the patient then taking case notes, making it difficult for patients to actively participate and feel empowered.
A powerful way to improve in-session communication is through the use of documentation tools, including questionnaires or templates, to allow smoother communication. By promoting patient-centered communication and empowering patients, tools like a well-designed physiotherapy assessment can improve patient outcomes.
Special Considerations When Doing Physiotherapy Assessments
Physiotherapy assessment processes can vary significantly across practice areas. Furthermore, each patient will have different goals and approaches that work for them in reaching those goals. Below is an overview of special considerations for conducting physiotherapy assessments in specific areas of clinical practice.
It’s also worth noting that since younger children may struggle with communication and complex instructions, the patient-physiotherapist relationship will also involve their parents and caregivers. When discussing goals with the patient and parents, these goals should be flexible, as children grow rapidly and their physical, social, emotional, and mental needs change just as quickly.
Stroke Assessment and Other Neurological Assessments
When assessing the physical ability of a post-stroke patient, the severity must be determined, usually using the NIH Stroke Scale. Apart from severity, the part of the brain that’s affected should be assessed.
Neurological physiotherapy sessions are primarily focused on examining motor function, coordination, balance, and overall functional independence. There are specific scales that can be used to measure these, such as the Fugl-Meyer assessment for motor function or the Functional Independence Measure (FIM).
Geriatric Physiotherapy Assessment
The geriatric population, especially those with multiple medical conditions, is at high risk for falls leading to serious injury. So as part of treating their physical limitations, it’s important to also treat or to consider chronic conditions and ongoing risks. Compared to younger adults going through physiotherapy, the exercises for geriatric patients are more low-impact and focused on retaining their ability to perform daily activities.
Sports-related Physiotherapy Assessment
Athletes’ livelihood depends on being able to participate in sports. Therefore, apart from helping them recover from injuries, sports-related physiotherapy assessment also focuses on enhancing athletic performance and preventing injuries. Additionally, the treatment regimen, while ideally targeting the whole body, should be tailored to the patient’s needs and the nature of the sports they play.
Apart from all these considerations, there’s another aspect that physiotherapists should not overlook—the mental and emotional health of each patient. Physical therapy can be frustrating because recovery is never a linear path.
Each session needs to make the patient feel like as well as their physical goals, their social and psychological needs, are being considered. The main way this crucial need is addressed is through effective patient-centred communication by the physiotherapist.
Lachlan Fooks, an experienced sports and exercise physiotherapist at Performe clinic, used to struggle with regularly having to turn his back to patients during consults to take notes. He also found that “additional administrative responsibilities like writing letters, managing referrals, and coordinating care, significantly eat into time with patients.”
Now, with Heidi’s AI medical scribe looking after his notes, Lachlan directly faces and interacts with his patients throughout the entire consult. He reports that this has significantly enhanced patient rapport and engagement. Plus, he saves 1.5+ hours on administrative work each day.
How to Write a Physical Therapy Assessment with Examples
There are multiple parts of a comprehensive physiotherapy assessment, and a template can streamline the process by helping clinicians to remember all the details. Most physiotherapy assessment templates start with the patient’s identifying information, followed by the sections detailed below.
Pertinent Medical History
This includes the history of the present condition, like the date of injury or start of symptoms, management undertaken to address the condition (including surgeries or other treatment), factors that aggravate or alleviate the pain or disability, and the associated symptoms that come with the condition.
Example note
“Patient is a 33-year-old man with a history of falling on his left arm 3 weeks ago. He underwent an open reduction, internal fixation operation for his left humerus. He notes pain whenever he overexerts his left arm, but no other associated symptoms.”
This part can also include the patient’s personal and social history, previous medical conditions and injuries, chronic care management plans, allergies, and current medications. History of smoking, drinking, and other relevant behaviors or activities should be noted as well as the patient’s occupation. Family history of disease that may be related to the patient’s condition may also be mentioned.
Imaging Tests
This is the part where the previous and the most recent imaging findings are noted. Detailed results from X-rays, MRIs, or CT Scans to provide a more exact location of the affected area and extent of injury.
Example note
“His previous x-ray before the operation revealed an oblique, transverse fracture of the left humerus”
Goals (Short-term and Long-term)
Discuss with the patient what they want to achieve by specific time points (e.g., the end of each session, after a few sessions, and further into the future). It’s important to consider the patient’s personal goals, physical ability, lifestyle, and occupation.
Example note
“In the short-term, patient wants to improve his range of motion within 4 weeks to return to his work as a sports coach as soon as possible. In the long-term, he wants to be able to at least demonstrate proper basketball throwing techniques without pain (within the next 2 months).”
Objective Findings
This section includes a systematic review of the patient’s physical findings from head to toe. Here, vital signs, anthropometrics, general appearance, review of systems (respiratory, abdominal, and cardiology-related findings), functional ability, prosthetics or use of aids, and signs of inflammation are noted. Myotome and dermatome testing may also be placed in this section.
Example note
“He has a heart rate of 88, blood pressure of 130/80, and respiratory rate of 18. He has no physical deformities, but has a recent scar on his left arm from his operation. Range of motion is intact, but notes slight pain on flexion of the wrist.”
This part should also check the functionality of various systems. Cranial nerves, mental status, motor function, muscle groups, resistance isometric movements, reflexes, joints, and specific tests for the patient’s condition are all listed here with their results.
Treatment
The clinical plan should be discussed in this section of a physiotherapy assessment. This includes the summary of the active therapy treatment being provided for the patient, the other medical plans the patient has in place, and treatment to be done in the next session (or at home).
Example note
“Patient understood his pain management strategies and continued taking his pain medication as needed. His active therapy includes wrist curls 3x10, hammer curls 3x10, and reverse curls 3x10”
Patient Education and Home Instructions
The findings of the physiotherapy assessment should be discussed with the patient, including whether their goals are being reached or if adequate advancements are being made. The patient should also be informed regarding what they can do at home to improve their progress, as well as what they should not do that may be detrimental to recovery. Afterwards, patients should be advised about their follow-up schedule with their physical therapist and if referral letters are required for any specialists.
Example note
“Patient noted less pain on the testing of range of motion by the end of this session. He was informed to continue light exercises at home. Next session should include more strengthening exercises. He was referred to orthopedics for his postoperative follow-up. His next session is schedule 2 weeks from now.”
Physiotherapy Assessment Template Example
Physical therapy involves a lot of hands-on tasks that make it hard to fully focus on the patient while also completing documentation. As a result, physiotherapists are placed in the difficult position of choosing between completing documentation after sessions (negatively impacting work-life balance) or interrupting patient care frequently to take notes (limiting rapport and engagement).
Easily Document Physiotherapy Assessments with Heidi
With the use of Heidi’s AI scribe, physiotherapists don’t need to worry about shifting between delivering care and writing notes. Instead, they can do both at the same time in 3 easy steps:
Transcribe: After getting consent from the patient, access Heidi on your preferred device and press Start. As you complete your assessment, Heidi automatically captures your findings.
Customize: Select your preferred template and Heidi organizes findings in your preferred format, ready for review.
Transform: You can also ask Heidi to produce other documents from your assessment, such as a referral letter, report, or patient summary.
Heidi complies with safety and security standards like, HIPAA, GDPR, PIPEDA, and APP, so you never need to worry about the safety of your data. Clinicians from across the globe trust Heidi to process more than 1.5 million patient sessions per week.
This physical therapy assessment template supports clinicians to complete comprehensive session notes during their first meeting with the patient. It details the history of present illness, signs and symptoms, pain assessment, activity limitations, and more.
This physio progress note template is ideal for progress notes, as it summarizes the current situation of the patient in brief paragraphs. The template is ideal for tracking progress in conditions such as back pain, sports injuries, and post-surgical rehabilitation.
This template is perfect for physiotherapists who work in an inpatient setting. It follows the more traditional SOAP format, along with specific inclusions relevant to physiotherapy. Apart from functional and mobility findings, the template summarizes the state of the patient in admission as well as the work-ups done in the hospital.
What are some key elements in a concussion physiotherapy assessment?
A concussion is a type of traumatic brain injury, so these assessments have considerations similar to neurological assessments. Concussion physiotherapy assessments usually begin with screening for neck pain, dizziness, and headache before moving on to more appropriate evaluations in relation to the patient’s clinical presentation.
What components should be in a Parkinson’s Disease physiotherapy assessment?
Goals of physical therapy for patients with Parkinson’s disease may include improving function, recovering lost function, and maintaining physical ability. Assessments should include the patient’s physical capacity, challenges in changing position, limitations in manual activities, quality of motion, posture, and balance.
How can I create my own musculoskeletal physiotherapy assessment template?
Once you’ve signed in to Heidi, simply click “Create” and then click on “Create new template” in the pop-up window. You can then input the details about your needs, and Heidi’s AI will generate the template, after which you can edit it as necessary. You can also select an existing assessment to create a template from or choose one from the Template Community and edit it.
