Physiotherapy Initial Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

HOPC
- [Describe history of presenting condition, including mechanism and date of injury, management since injury, etc] 
- [Describe factors that aggravate and ease the pain]
- [Describe the pain over the duration of 24 hours]

Radiology:
- [List any radiology assessment and their findings that have been undertaken for this patient's presenting complaint/injury]

Past Medical History
- [List existing and past medical conditions, e.g., osteoporosis, stroke, high blood pressure, surgeries etc, with brief description and management, e.g. Amlodipine 5mg QD]
- [Mention any allergies]

Social History
- [Mention relevant social history like lifestyle factors, living arrangements, support network, tobacco/alcohol use, etc]
- [Mention family medical history of disease that may be relevant to their presenting condition or may impact their response to therapy]
- [Summarise employment status, occupation, hours worked, physical/mental intensity of job, etc]

Goals
- [Short-term physiotherapy goals & time frame for achieving these goals]
- [Long-term physiotherapy goals & time frame for achieving these goals]

Objective
- [List all physical observations and examinations completed, along with their findings]

Treatment
- [List all educational treatment provided throughout session, e.g. pain science education]
- [List all hands-on treatment provided throughout session, e.g. Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc]
- [List all active therapy treatment provided throughout the session, e.g. 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc]
- [List home exercise program (HEP) provided, including reps, sets, and frequency]

Assessment
- [Summarise the assessment and state diagnosis based on subjective and objective findings]
- [Summarise the assessment and state differential diagnosis based on subjective and objective findings]
- [Summarise their progress towards their stated goals]
- [State any barriers affecting progress]

Plan:
- [Brief summary of the clinical plan until the next appointment]
- [Timeline of next review]
- [Likely therapy to be provided at next appointment]
- [Referrals to other professionals that need to occur or the patient will attend] 
- [Letters, phone calls, or communication the treating therapist will do before next session]