Patient Records and Case History for Physiotherapy Clinics
Each patient has one record holding registration details, the presenting complaint, medical history and the referring doctor. Every course of treatment is added to it, so a returning patient is not started from scratch.
What the patient record holds
The front desk opens the record at registration, and therapists add to it from the first assessment onward.
Who uses the record
Reception registers patients, finds them by phone number and reads the balance of any package. Therapists read the history before a session. The owner can see how many new patients came in a month and from where.
Where the record leads next
A completed registration moves the patient straight to a first appointment. The assessment, the plan and every later session note attach to this same record, so no detail is entered a second time.
What the clinic decides
- Which fields are compulsory at registration, and which are left to the therapist.
- Who may read the history, set by role for each person on the team.
- How old paper files are brought in, whether all of them or only active patients.
- How long a closed case stays easy to reach before it is archived.
What the record does not do
It stores what the clinic writes down. It does not diagnose or suggest treatment. Clinical judgement stays with the therapist, and how long records must be kept is for the clinic to confirm with its own advisor.
Frequently asked questions
Can scanned referral letters and reports be attached?
Yes. A photo or scan of an X-ray report, MRI report or doctor’s letter can be attached to the patient’s record and opened from any visit.
How does the desk find a patient who has changed their phone number?
Search works on name as well as phone number, so an older record can be found and its number updated without making a duplicate.
Does each branch keep its own list of patients?
No. A clinic with two branches shares one patient list, so a patient who moves between branches keeps a single history.
Can a patient’s old paper file be brought in?
Yes, where the clinic chooses to. Active patients are usually entered first, and the scope of older files is discussed during set-up.
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