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Physio documentation template

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Physio documentation template, assessment report template, documentation, record keeping

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Physio documentation template

  1. 1. INSERT DATE Ref: Patient Name: PLEASE COMPLETE Date of Assessment: PLEASE COMPLETE Nature of Injury/ Illness: PLEASE COMPLETE Current Occupation: PLEASE COMPLETE Practitioner Name: PLEASE COMPLETE INJURY/ ILLNESS DETAILS History of presenting problem Please provide a description of how the client was injured and their current presenting complaint. Any related pre-existing problems? Please provide details of pre-existing problems in injured area and any other relevant aspect of medical history which can impact on recovery and rehabilitation MEDICAL INFORMATION Is the client taking medication? Please provide details of client's current medication along with dosage and frequency EXAMINATION Subjective markers Please provide details of any subjective markers used e.g. pain, stiffness VAS etc. Objective markers
  2. 2. Please provide details of any baseline objective evaluation measures assessed e.g. ROM, Strength, Reflexes, etc. Please ensure that exact scores or grades are provided Comment on Work Status -Please include dates that the client left and returned to work (if applicable) - Please state whether the client is working full time on light/full duties Interference with hobbies? Please provide details of any hobbies which client is unable to participate in, due to presenting problem. Social situation TREATMENT DETAILS & PROGNOSIS Treatment Goals Current treatment plan Next review date Consent agreed, and form signed?

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