Edit note template

Treatment note · shared with the team: they can use it, not change it

Name

3 to 140 characters. Shown on Record session and as the note title in Cliniko.

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.

Set as my defaultRecord session starts with this note template. Share with teamEveryone at Trent Valley Physio & Rehab can use it. Only you can change it.

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Sections detected

5 sections, in this order

1Subjective
2Objective
3Treatment
4Analysis
5Plan