Quick-entry format for routine treatment sessions. What changed, what you checked, what you did, how the patient responded, what happens next — in 2 to 4 minutes.
The daily note does not repeat the initial assessment. It captures only the clinically relevant change since last session, the key reassessment, the treatment delivered, the response, and the next clinical decision.
The detailed ICF problem list, SMART goals, rehabilitation phases, treatment plan and progression criteria stay in the initial assessment — the rehabilitation roadmap. The progress note points back to it.
Phase-specific goals, planned interventions, outcome targets and progression / discharge criteria — pre-populated into the progress-note screen so the therapist can review them before the appointment starts. It also pre-populates the previous session's subjective and objective findings, so today's can be compared and the improvement status recorded.
Used every session to record change, intervention, response and the next clinical decision. Separating the two reduces repetitive writing, improves clinical reasoning, and makes daily documentation faster and more auditable.
Date & time of the follow-up appointment
| Overall (patient's perception) | Better Same Worse |
| Present pain VAS ___/10 | Less Same as previous session Worse Not applicable Area of pain: |
| Swelling | Less Same Worse Not applicable Area of swelling: |
| Mobility | Less Same Worse Not applicable Area of concern: |
| Function / activity status | Present PSFS scores; activity limitation and participation status for the day. |
| Response to last session | Good Temporary improvement Expected soreness Symptoms aggravated |
| Home exercise programme | Done Partial Not done Training / activity change: |
| New red flags / medical concerns? | No Yes — details: |
Record only findings that influence today's treatment or progression. Do not repeat the full assessment. The body-structure-and-function items from the initial assessment are pre-populated; the therapist re-measures only those items and records today's value against last time.
| Reassessed | Pain / swelling ROM / mobility Strength / flexibility Motor control / balance Movement pattern Gait / running Functional task Sport-specific task |
| Finding / measure | |
| Compared with previous session | Improved Same Worse |
| Rehab phase today | Phase 1 acute / symptom Phase 2 strength / neuromuscular Phase 3 function / return to sport |
Tick the categories, then record the actual exercise and dose.
Symptom management Manual therapy Mobility Neuromuscular re-ed Strengthening Balance Movement control Functional retraining Gait / running Conditioning Plyometric / agility Sport-specific rehab Education / load management HEP reviewed / progressed Other
| Exercise / intervention | Dose / load | Modifications / additions |
|---|---|---|
| The goals and treatment plan for the patient's current phase (set at the initial assessment) are pre-populated. The therapist selects from the list, highlighting what was actually used this session. | Entered by the therapist from the patient's tolerance today — sets, reps, load. | Any change to the planned exercise, based on today's baseline and tolerance. If none: select "no modification / addition to the existing plan". |
| Post-treatment pain ___/10 | Response: Better No change Expected fatigue / soreness Increased |
| Movement / function | Improved Same Worse Not reassessed |
| Tolerance to the session | Good Moderate Limited |
| Clinical interpretation | Progressing as expected Needs modification Plateau Regression Reassess |
| Clinical comment for the day |
| Next session | Continue Progress load / volume Progress ROM Progress motor control / function Progress activity participation (running / agility / sport-specific) Modify / regress the present plan Reassess / outcome measures Refer to another consultant / senior |
| Specific next-session focus | |
| Progression status | Continue phase Approaching criteria Ready for next phase Not ready |
| Criteria still to achieve | |
| HEP | Continue Progressed Modified New exercises — previous HEP is pre-populated; continue or modify. |
| Next appointment | Date & time |
| Keep the daily note short | Do not reproduce the initial examination at every visit. Document only changes and findings that influence today's treatment or progression. |
| "Treatment delivered", not "treatment planned" | What was actually provided is more clinically useful and more defensible than intention alone. |
| Link every note to the rehab phase | The Phase 1 / 2 / 3 tick box connects the session to the roadmap and shows progression over time. |
| Make the Analysis meaningful | Avoid routine phrases such as "tolerated treatment well". Record symptom response, movement / functional response, exercise tolerance and clinical interpretation. |
| Use progression criteria in the Plan | State whether the patient stays in phase, is approaching criteria, is ready to progress, or needs regression / reassessment. |
| Keep outcome measures periodic | PSFS and other outcome measures are not needed every session — use them at baseline and planned reassessment points. SOTAP captures brief session-to-session change. |
| Retain safety screening without long checklists | One concise daily item for new red flags or medical concerns; detailed escalation criteria stay in the main documentation system. |
| Section | Example |
|---|---|
| S | Overall better. Pain 5/10 → 3/10. One flight of stairs with less discomfort. HEP 5/7 days. No new red flags. |
| O | Squat to 70° with mild dynamic knee valgus; pain 3/10. Single-leg control improved. Phase 2. |
| T | Hip abductor strengthening 3×12; split squat 3×10; step-down 3×8; single-leg balance 3×30 s; load-management education. |
| A | Post-treatment pain 2/10. Improved squat depth and frontal-plane control with verbal cueing. Strength work tolerated without symptom increase. Progressing as expected. |
| P | Progress split-squat / step-down load if pain remains ≤3/10 and returns to baseline within 24 h. Continue HEP. |