Edit starter note

Treatment note · copied to every new clinic at sign-up

Name

3 to 140 characters. New clinics see it in their template list.

Note structure

Subjective:

Include all relevant patient-reported details about the injury:
- Location of pain or symptoms
- Mechanism of injury (how it happened)
- Duration and progression of symptoms
- Any history of similar injuries
- Aggravating or easing factors
- Whether they've had any scans or imaging (X-ray, MRI, etc.)
- Previous treatment or management (e.g. physiotherapy, surgery, medications)
- Impact on daily life or function

Objective:

Document all clinical assessment findings, including:
- Range of motion (active/passive)
- Strength testing
- Special tests and their outcomes (e.g., orthopaedic or neuro tests)
- Palpation findings
- Observation/postural analysis
- Any relevant neurological signs (reflexes, sensation, power)
- Functional movement assessments

Treatment:

List any treatment performed during the session, such as:
- Manual therapy techniques (e.g., joint mobilisation, soft tissue release)
- Modalities (e.g., shockwave, acupuncture, taping)
- Exercise prescription or rehab introduced
- Education/advice given
- Modifications or support for work/sport
- Any referrals made or investigations discussed

Analysis:

Provide clinical reasoning and interpretation:
- Impression or working diagnosis
- Response to treatment during the session
- Any differential diagnoses
- Clinical summary of key findings
- Thoughts on severity, irritability, or stage of healing

Plan:

Outline the ongoing management plan, including:
- Frequency/duration of future sessions
- Home exercise programme or self-management strategies
- Advice regarding return to activity/sport/work
- Referrals for imaging or specialist review if needed
- Long-term goals and outcome measures

Write each section heading on its own line, then what it should cover.

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Sections detected

5 sections, in this order

1Subjective
2Objective
3Treatment
4Analysis
5Plan