Absolutely!
Here's a detailed explanation of the physiotherapy documentation guidelines,
including why each component matters, how to document effectively, and what to
include under each heading:
🗂️1. General Principles of Documentation
These are the foundational rules for keeping physiotherapy records:
✅ Accuracy
Record only what you’ve observed, measured, or what the patient reported.
Avoid assumptions—stick to facts.
Example: Instead of "patient seems better," write "patient reports decreased pain from
7/10 to 4/10 on VAS."
✅ Clarity
Use simple, professional language.
Avoid unnecessary medical jargon that might confuse others reading the file (e.g.,
interns or referring physicians).
✅ Legibility
If handwritten, ensure it's readable. If digital, use structured templates and proper
formatting.
✅ Timeliness
Notes should be written immediately or shortly after the session to avoid memory
errors.
Delayed documentation can lead to legal issues or treatment errors.
✅ Confidentiality
Store notes securely.
Don’t share records unless legally required or with patient consent.
Comply with laws like HIPAA (USA), GDPR (EU), or local privacy regulations.
📝 2. Components of Physiotherapy Documentation
Each part of the physiotherapy record has a clear purpose and content:
A. Initial Assessment
This section provides a baseline and helps guide treatment planning.
🧑 Patient Identification
Name, age, sex, hospital/clinic ID, date of assessment
Essential for tracking and avoiding mix-ups
📄 Referral Information
Name of referring doctor (if any), reason for referral
Helps understand medical context (e.g., post-operative rehab)
🗣️Subjective History
Chief complaint: "Why are you here?"
History of present illness: Onset, duration, progression
Pain: Use scales (e.g., VAS/NPRS), describe location, nature (sharp, dull), timing,
aggravating/relieving factors
Functional limitations: e.g., "Can't walk more than 10 minutes without pain"
Previous treatment history: Medications, surgeries, therapies
Lifestyle factors: Work, hobbies, physical activity
👀 Objective Examination
This section includes physical tests and observations:
Observation: Posture, gait, swelling, deformities
Palpation: Tenderness, temperature, muscle tone
ROM: Measured with goniometer or visually estimated
Muscle strength: Manual Muscle Testing (MMT)
Neurological signs: Sensation, reflexes, coordination (if needed)
Special tests: e.g., Straight leg raise, Phalen’s test
Functional tests: Sit-to-stand, 6-minute walk, etc.
B. Assessment/Physiotherapy Diagnosis
Clinical interpretation of findings
Identify key problems: pain, weakness, loss of ROM, balance deficit
Use the ICF model if possible:
o Body functions/structures: e.g., decreased ankle dorsiflexion
o Activity limitations: e.g., difficulty walking
o Participation restrictions: e.g., can't attend work
C. Goal Setting
Goals must be patient-centered and follow the SMART framework:
Specific: Improve left knee flexion
Measurable: From 60° to 120°
Achievable: Based on condition and baseline
Relevant: Helps patient return to function
Time-bound: Within 4 weeks
Example:
"Patient will increase right shoulder abduction from 90° to 160° in 3 weeks to enable
overhead dressing."
D. Treatment Plan
Detailed plan based on diagnosis and goals:
Intervention type: e.g., manual therapy, TENS, exercise therapy
Frequency/duration: e.g., 3 sessions/week for 4 weeks
Education: Ergonomics, posture correction
Home Exercise Program (HEP): Clear instructions, frequency, reps
Include rationale for chosen interventions
E. Progress Notes (Daily or Weekly)
Use the SOAP format:
🟡 S – Subjective
What the patient reports
e.g., "Patient says back pain is better in the morning but worsens after long sitting."
🟢 O – Objective
Observations and reassessments
e.g., "SLR improved from 30° to 60°, lumbar flexion increased by 10°."
🔵 A – Assessment
Clinician’s interpretation of the session
e.g., "Improved ROM indicates progress toward functional goal."
🟣 P – Plan
What’s next? Continue or modify treatment?
e.g., "Continue with strengthening exercises and add core stabilization."
F. Re-evaluation / Review
Done every few weeks or at key milestones
Repeat measurements (ROM, strength, pain)
Compare with initial findings
Modify goals if needed
G. Discharge Summary
When treatment ends (goal achieved, referred, or patient quits)
Include:
o Duration of care
o Goals achieved/not achieved
o Final outcomes (ROM, strength, function)
o Discharge instructions (home program, precautions)
o Follow-up advice
🔒 3. Legal and Ethical Guidelines
Sign/date every entry (include designation, e.g., "PT")
If a mistake is made:
o Cross with a single line, write “error,” and sign
Standardized abbreviations: Helps others understand your notes
o Example: AROM = Active Range of Motion, MMT = Manual Muscle Testing
Maintain records for 7–10 years (or as per regional law)
📚 4. Templates & References
If you want structured formats, refer to:
APTA Documentation Guidelines (USA)
CSP Record Keeping Guidelines (UK)
WCPT Toolkit for Documentation
Your local health ministry or hospital SOP
Would you like a printable template or sample notes for a specific condition like stroke,
ACL rehab, or back pain? I can create one tailored to your need.
