Including previous ROM is a quick way to document progression or regression. Neer Impingement (-), Apprehension test (-), Drop arm (+), etc. Include only the most relevant tests and indicate whether it is a positive (+) or negative (-) finding.įor example: ex. It’s important to include relevant special tests in your Objective report – keyword, “relevant.” Don’t include every possible special test that would make it difficult for the physician to locate pertinent findings. I’ve included a line for this summary in my sample progress note template. Your treatments may include the following: therapeutic exercise, manual therapy, neuromuscular re-education, balance/gait training, iASTM, E-Stim, Ultrasound, etc. This gives the physician an idea of how many visits/cancellations their patient has had as well as the types of treatments you’ve provided. ![]() Summary of Treatment ProvidedĪ progress note also reports a summary of provided treatments and the number of completed visits. He is now able to reach head-level without sharp pain in his shoulder. The patient reports 3/10 pain in his shoulder, but feels that he has been getting stronger overall since starting PT. Give a brief statement on how the patient feels they have been progressing since starting PT (their subjective experience of therapy). ![]() Let’s take a look at important items to include within a given physical therapy progress note. Sometimes it’s helpful to put a star or asterisk next to an important finding if you feel that it might go unnoticed in the rest of the progress note. Be clear and to the point as you highlight key findings in your assessment. ![]() When writing a progress note, understand that the physician may have less than a minute to review your notes. Objective: ROM, strength, special tests.Subjective and Summary of Treatments Provided.In keeping with SOAP, a progress note typically includes the following: This kind of note can also take the place of a daily note, since it follows the standard SOAP formula for daily documentation. If you’re wondering how to write a progress note or need some templates to get you started, I have just the resources to help you out! How to Write a Progress NoteĪ therapy progress note updates a prescribing physician on their patient’s current status towards their rehab goals. You became a physical therapist to help people move better, but part of your job involves writing documentation, such as daily notes or therapy progress notes.
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