How every Pro Physio MSK initial assessment is written up — the ICF problem list, SMART goals, and a three-phase treatment plan with progression and discharge criteria. This is the rehabilitation roadmap that every SOTAP progress note refers back to.
Four sections, in this order. Together they form the rehabilitation roadmap that the SOTAP progress note refers to at every session.
Impairments, activity limitations, participation restrictions and contributing factors — organised under the ICF framework.
SMART goals for each phase, drawn from the problem list and the PSFS.
Phase 1, 2 and 3 plans with explicit criteria to move between phases.
Baseline measures and the targets each phase is working towards.
Summarise under the following subheadings. Each is a separate line in the report, even if the entry is "none found".
| Ref | Subheading | What goes here |
|---|---|---|
| 1a | Pain findings | Location, behaviour, irritability, aggravating and easing factors, VAS. |
| 1b | Muscle performance deficits | Strength and power deficits by muscle group, side-to-side comparison. |
| 1c | Muscle flexibility deficits | Length deficits and the joint range they limit. |
| 1d | Motor control deficits | Timing, activation and co-ordination faults observed during testing. |
| 1e | Movement dysfunction | Faulty patterns seen in functional tasks — squat, step, gait, running, sport task. |
Summarise from the subjective and objective examination findings — the tasks the patient cannot do, or does with difficulty or symptoms.
The life roles affected — work, sport, household, caring, social. Keep these in the patient's own words where possible.
The modifiable and non-modifiable factors that explain why the problem exists or persists. A typical knee presentation, for example, might list:
Goals and plan are written per phase. Every plan section refers to the most recent published guidelines for best practice, and every phase ends with the criteria for moving to the next.
Goals focus on:
Based on the problem list, irritability status and acute-phase goals, set out a detailed plan for:
| Pain and acute symptom management | Approach matched to irritability and symptom behaviour. |
| Electrotherapy modalities | With suggested dosage based on symptom presentation and behaviour. |
| Manual therapy | Options that can be used in this phase. |
| Flexibility / mobility work | |
| Neuromuscular re-education | |
| Functional retraining | |
| Prescription dosage | Sets, reps, load, frequency. |
| Patient education | An education and awareness plan built from the patient's condition, findings and acute goals. Refer to recent evidence-based guidelines; include information or video links that can be forwarded to the patient. |
| Home programme | With dosage. |
| Criteria for progression to Phase 2 | Explicit and measurable. |
| Clinical pearls | For the treating therapist in this phase, drawn from the subjective and objective findings. |
Write the plan under each heading. For flexibility, neuromuscular re-education and strength, cover all the areas the assessment showed need intervention — not just the primary complaint.
Identify the Phase 3 goals, then write the plan under each heading:
| Progressive resistance training | |
| Functional integration | |
| Dynamic stability | |
| Muscular endurance | |
| Cardiovascular retraining | |
| Prescription dosage | |
| Patient education | Guideline-based; include links the patient can keep. |
| Home programme | |
| Clinical pearls | For this phase, from the assessment findings. |
| Criteria for discharge / discontinuation | When ongoing rehabilitation and training stops, and what the patient continues independently. |
The problem list, goals, phases and criteria live here, written once. Daily SOTAP notes then record only change, intervention, response and the next decision — they never repeat the assessment.
Week ranges are guides. A patient moves phase when they meet the written progression criteria — which is why every phase must state them.
Every treatment plan section refers to recent published guidelines. Patient education material is evidence-based and shareable — links the patient can open at home.
In Phases 2 and 3, flexibility, neuromuscular and strength work address all areas the assessment flagged, not only the presenting region.