Assessment and Progress Notes for Physiotherapy Patients
The first assessment captures findings and goals, and a short note follows each session. The clinic sets the note format, so every therapist writes in the same order and the next one reads it quickly.
From assessment to session note
The first visit is longer and the later visits are shorter. The record follows that shape.
Reading notes across therapists
A patient may see a different therapist on a day the usual one is off. The notes are in the patient’s record, in date order, so the cover therapist can pick up where the last session ended.
Notes that are late
A session marked done without a note appears on a pending list. The owner and the therapist can both see it. Notes written a week late are usually thinner, so the list is there to catch them early.
What the clinic decides
- The headings and scales used on the assessment form.
- How long a session note should be.
- Which notes a therapist may edit afterward, and which are locked.
- Whether patients may be shown their own notes.
What this page does not cover
The notes record what the therapist found and did. The software does not interpret findings or recommend a technique. Clinical standards for documentation are a matter for the clinic and its professional body.
Frequently asked questions
Can the assessment form match what we use today?
Yes. Headings, scales and tick boxes are set to your current form during implementation, so therapists are not asked to learn a new order.
Can a therapist add a note from a phone?
Yes. A therapist can open the patient’s record on a phone between sessions and write the note there instead of waiting until the evening.
Are photos of posture or wounds supported?
Yes, as attachments to the record. Whether and when a clinic takes such photos, and with what consent, is the clinic’s decision.
Can a note be corrected after it is saved?
Where the clinic allows it. A correction can be kept as a dated edit, so the original wording is not lost.
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