Note

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