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Templates, Clinical notes, Physiotherapy

Physiotherapy follow-up note template

A physiotherapy follow-up note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Follow-up note

TemplatePhysiotherapy

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Physiotherapy follow-up note

1Since the last visit

  • What has changed since the last visit, in the patient's words.
  • Results received since the last visit, and whether they were discussed.

2Examination

  • Observation, range of movement, strength and special tests, with the values recorded.
  • Neurological examination where indicated.

3Review

  • The clinical impression, and the structures likely involved.
  • Outcome measure scores at baseline.

4Plan

  • Treatment given and the home exercise programme agreed.
  • Number of sessions planned and the goals for each stage.

5Next review

  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Follow-up note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Physiotherapy follow-up note

1Since the last visit

  • Pain on stairs reduced. Good adherence to exercises.00:40

2Examination

  • Full range of movement. Pain on single leg squat. Tender at the inferior patellar pole.05:10

3Review

  • Likely patellar tendinopathy related to a rapid increase in load.06:30

4Plan

  • Load management advised. Home exercise programme started. Six sessions planned.07:20

5Next review

  • Advised to report swelling or locking.08:00

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a physiotherapy follow-up note?

Since the last visit, Examination, Review, Plan and Next review. Each section on this page lists what belongs in it, written for physiotherapy.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The follow-up note in other specialties

All clinical notes
  1. Private GPPrivate GP follow-up note
  2. DermatologyDermatology follow-up note
  3. AestheticsAesthetics follow-up note
  4. FertilityFertility follow-up note
  5. Mental healthMental health follow-up note
  6. DentalDental follow-up note
  7. Longevity medicineLongevity medicine follow-up note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

Come back to the note, written and ready to sign.

See the wai scribe write a physiotherapy follow-up note on your own structure, in a 15 minute video call.

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