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Templates, Clinical notes, Physiotherapy

Physiotherapy initial consultation note template

A physiotherapy initial consultation 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.

01Initial consultation note

TemplatePhysiotherapy

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

Physiotherapy initial consultation note

1Presenting complaint

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.

2History of the presenting complaint

  • Mechanism of injury, onset and aggravating and easing factors.
  • Function lost, and the patient's goals for treatment.

3Past history, medicines and allergies

  • Relevant medical history and red flag screening.
  • Current medicines and allergies.

4Social and family history

  • Occupation, smoking, alcohol and anything else relevant to the complaint.
  • Family history where it changes risk or management.

5Examination

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

6Impression

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

7Plan

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

8Safety-netting

  • 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.

01Initial consultation note

SignedAI-assisted, edited by the clinician

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

Physiotherapy initial consultation note

1Presenting complaint

  • Right knee pain for one month since returning to running.00:30

2History of the presenting complaint

  • Worse on stairs, especially descending. Eases with rest. Goal is to return to 10 km runs.01:50

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

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

6Impression

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

7Plan

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

8Safety-netting

  • 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 initial consultation note?

Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. 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 initial consultation note in other specialties

All clinical notes
  1. Private GPPrivate GP initial consultation note
  2. DermatologyDermatology initial consultation note
  3. AestheticsAesthetics initial consultation note
  4. FertilityFertility initial consultation note
  5. Mental healthMental health initial consultation note
  6. DentalDental initial consultation note
  7. Longevity medicineLongevity medicine initial consultation 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 initial consultation note on your own structure, in a 15 minute video call.

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