Page one is what the patient tells you. Go through the red flags with every new patient: a tick there means the patient needs a doctor’s opinion before treatment starts.
Page two is what you find. Record range of motion for both sides, so the next review compares like with like, and write goals the patient can check themselves, such as climbing stairs without holding the rail.
In MyClinicDesk, each session is saved as a visit on the patient’s record, and reminders for the next session go to the patient on WhatsApp. See MyClinicDesk for physiotherapy clinics.
What does a physiotherapy assessment form include?
The subjective part: the complaint, how and when it started, the pain, medical history and red flags. The objective part: observation, palpation, range of motion, muscle strength and special tests. Then the physiotherapy diagnosis, goals and the treatment plan.
Which pain scale does this form use?
An 11-point numeric rating scale from 0 to 10, where 0 is no pain and 10 is the worst pain the patient can imagine. Asking the same question at each review shows whether treatment is working.
How is muscle strength graded?
On the Medical Research Council scale, from 0 to 5: 0 is no contraction, 1 a flicker or trace of contraction, 2 active movement with gravity eliminated, 3 active movement against gravity, 4 active movement against gravity and resistance, and 5 normal power. The MRC scale is used with the permission of the Medical Research Council.
MyClinicDesk saves each physiotherapy session as a visit, tracks payments, and reminds patients of their next session on WhatsApp.
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