Clinical Notes Summary & Template (2018)

Please use the following headings (underline or bold if typed) to complete your clinical note entry. Mark your
subjective & objective comparable signs with an asterisk (*) or by highlighting in bold (if typed). You may use
abbreviations for the headings & common abbreviations within your text.

Subjective Exam (SE) (all these sections should be addressed in your clinical notes)
Body Diagram:
• Mark area(s) of pain (&/or other symptoms) & use informative labels (eg PLx for lumbar pain)
• Mark/document other symptoms as relevant (P&Ns, N, weakness, apprehension, giving way, locking,
clicking, dizziness etc)
• Document relationship between areas of pain &/or other symptoms (eg ↑ PLx results in onset Pleg)
• Intermittent vs constant
• Nature (eg ache, sharp, shooting, stiff feeling etc)
• Intensity of pain (&/or other symptoms) at worst, on average, at best (if constant) – NRS, VAS, qualitative
statement (mild/mod/severe)
• Depth of pain (or other symptoms)
• Clear other areas with √
Presenting Complaint (or Problem) (PC): Brief statement why patient is attending eg’s: “ intermittent (R) back &
posterior thigh pain”, “LBP with sustained sitting”
Social History (SHx):
• Get early as it will help direct rest of SE
• Occupation - nature, specific physical demands, hours, lost time/off work
• Physical activities or exercise – what, duration, frequency
• Sport (if relevant) – what, level, frequency of training/games, change in load over time, upcoming
competitions, lost time
• Hobbies, leisure, ADLs etc – how day is spent more generally (if relevant)
Current History (CHx) (or HPC) & Treatment (Rx):
• MOI/onset of symptoms (date, over what period) – traumatic vs non-traumatic (overload/overuse vs
insidious)
• Progression since onset & current status (improving, same, worsening & in what way eg location, severity)
• Treatment/management to date & effects for current episode (be specific)
• Medical (or other healthcare practitioner opinions) if relevant
Past History (PHx) & Rx:
• Previous episodes of this problem or related problems
• Frequency & severity of episodes – increasing, same, decreasing
• Ease of aggravation, time taken to resolve, degree of resolution etc of previous episodes
• Other relevant PHx
• Previous treatment/management & effects (be specific)
• Medical (or other healthcare practitioner opinions) if relevant
Aggravating Factors (Aggs):
• Activities, movements, repeated loading, sustained postures or positions - directional bias?
• Start with open questions & use closed questions as required to confirm/negative diagnostic hypotheses,
confirm pattern & nature of provocation etc
Easing Factors (Eases):
• Clarify presence of mechanical easing factors through closed questions if necessary – directional bias?
• Coping strategies active or passive?

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Clinical Notes Summary & Template (2018)

Irritability (Irrit): Need to know how long/how much to aggravate, how severe does it get (has to stop, can continue,
has to modify), how quickly or easily symptoms settle again to baseline (based on 1 or 2 key aggravating factors)
Functional (Fx’al) Impairments: What can’t the patient do due to the presenting problem? Must differentiate true
functional impairment from activity simply “aggravating” the problem. May or may not be evident from aggravating
factors & history.
24 hr Behaviour:
AM: Pain vs stiffness vs both; time to ease
PM: Pain (symptom) pattern through day
Night: When first lays down vs wakes through night. If night pain present, spontaneous vs with movement;
sleep quality; sleep position (if relevant)
Medications (Meds):
• See Medical History Form (where available) & record medications here
• Dose & effectiveness for current disorder
• Screening for corticosteroids & anticoagulants – record here from Medical History Form (where available)
• Double check of GH
• Document “nil” if nil
Investigations:
• Document date & main findings, copy reports, view images
• Patient’s understanding of results
• Document “nil” if no investigations completed
General Health (GH), Screening & Precautionary Questions:
• Record relevant information here from Medical History Form (where available) ie “YES” responses
• If considered relevant (may or may not be listed on Medical History Form) ask: constitutional symptoms
(unexplained weight loss, fever, fatigue etc), heart/circulatory conditions, lung/respiratory conditions,
diabetes, thyroid dysfunction, cancer, osteoporosis, epilepsy, OA, RA, major operations, IV drug use,
infectious diseases, recent infection
• Bowel or bladder disturbance; saddle anaesthesia or paraesthesia; sexual dysfunction
• Gait, balance or coordination disturbance (signs/symptoms of myelopathy)
• Weakness, clumsiness, loss of fine motor control in hands (signs/symptoms of myelopathy)
• Cranio-cervical arterial pathology eg 5Ds/N
• Always record what was screened (ie asked) even if negative response (negative responses recorded on
Medical History Form do not need to be recorded again here)
Beliefs/Understanding/Expectations/Psychosocial Factors/Goals: Ask & document at minimum:
• What do you think or understand is causing your pain/problem?
• What do you think will help?
• What do you expect from physiotherapy?
• If off sport or work: When do you hope to return and when do you think you will be able to return?
Screening Tools (eg Short Form Örebro): Document score & document which domains/questions were scored high
as these are important comparable signs. Record information sought from patient about WHY certain questions
scored high.

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Clinical Notes Summary & Template (2018)
Objective (Physical) Exam (PE)
You are only required to document relevant sections for each individual patient. However, it is also important to
document negative findings for certain aspects of the assessment eg neurological examination, NTPTs, screening
tests etc to acknowledge that testing has been performed. You can use the labels from the body diagram to express
relevant symptom reproduction. All equipment should be available prior to beginning your assessment (eg reflex
hammer, linen etc). Patient must disrobe adequately but be mindful of modesty (ie drape). Note any resting
symptoms (location, intensity) prior to starting.

Spinal Assessment
Observations (Obs):
• Muscle tone, swelling, bruising, deformity, alignment, symmetry, scars etc
• Include provocative postures or positions
• Document any change in symptoms if posture or position is altered
Functional Tests (Fx’al Tests):
• Including tests of kinetic chain “capacity” & spring function (where relevant)
• Document quality of movement
• Document any unhelpful pain behaviours
• Document symptom response (location, severity) & range or position of spine when symptoms occur
• Document any change in symptom response &/or performance if movement or loading strategy is altered
Screening: Document what area(s) & which tests
Active Range of Motion (AROM):
• Document spinal region tested & which movement planes were assessed even if no symptom response (on
initial assessment)
o Full, pain free movement with over pressure = √√
• Document quality of spinal movement, range of onset of P1 (if relevant), range available (degrees, fractions
or finger tips landmark (lumbar spine)), symptom response (location & severity), limiting factor (R2 vs P2 or
other) & response with passive over pressure (if tested)
• Document any change in symptom response or range if movement strategy altered
• Note “pattern” of movement restriction &/or pain provocation
Combined Movements: Document range of onset of P1 (if relevant), range available (degrees, fractions or finger tips
landmark (lumbar spine)), symptom response (location, severity), limiting factor (R2 vs P2 or other)
Repeated Movements: Document effect on range & symptom response (including peripheralisation/centralisation)
Sustained Movements/Positions: Document time to symptom onset (or increase)
Neurological Exam (PNS, CNS, tests of central hypersensitivity):
• Document which tests were performed & response even if normal
• Strength: record Grade 0-5 or qualitative statement eg “weak”, “very weak” etc
• Reflexes: record as normal, hyper-reflexive, hypo-reflexive/diminished or a-reflexive/absent
• Light touch: record as normal, decreased, absent, increased (hypersensitive), allodynic or dysaesthetic
response (consider both “gain” (ie hypersensitivity) & “loss”)
• Sharp: record as normal, reduced (less sharp), absent or hyperalgesic response (consider both “gain” (ie
hypersensitivity) & “loss”)
• Other eg vibration sense, position sense, 2-point discrimination, cold/heat detection thresholds, cold/heat
hyperalgesia
• CNS:
o Babinski: record as down-going/absent (ie normal) or upward/extension response (ie abnormal)
o Clonus: record as absent or present; if present, number of beats & symmetry between sides
o Other: tests of balance, coordination, assessment of muscle tone
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Clinical Notes Summary & Template (2018)

Neural Tissue Provocation Tests (NTPTs)/Neurodynamic Tests:

• Document which test(s) were performed & sequence of limb movements if deviate from “standard”
sequencing (particularly relevant for upper limb)
• Document range (degrees), symptom response (location, severity, nature), any differences in resistance
through range compared to unaffected side & response to differentiation/sensitising/de-sensitising
movements on range/symptom response
• Document range & response to differentiation/sensitising/de-sensitising movements (if tested) including
unaffected side (to allow comparison to affected side)
Nerve Trunk Palpation:
• Document nerve, position tested (eg on length or shortened position), symptom response (“the pain”,
severity)
Physiological Motion Palpation:
• Document motion segment (level) & plane of movement
• Document whether hypomobile or hypermobile (not a pain provocation test but if pain reproduced,
document this)
• Generally acceptable to only document abnormal findings rather than all levels/all directions tested
• Example: Flexion L4/5 hypomobile
Palpation:
• Be specific as to which structure or landmark – bony or soft tissue
• Document response – pain, “the pain”, increased tone, temperature etc
Pain Provocation Tests (previously called Accessory Motion Palpation):
• Document contact point (eg spinous process, articular pillar, transverse process, rib), direction of pressure
(PA, transverse, AP), motion segment position if out of neutral & segmental level
• Document pain response (location, severity, “the pain”?) - most important
• Document if “stiff” (tissue compliance) – of secondary importance
• Document limiting factor especially if P2 (R2 vs P2)
• Can use “squiggles & lines” to represent pain & stiffness respectively
• Generally acceptable to only document abnormal/relevant findings rather than list all tests performed
• Example: (R) unilateral PA L4/5 PLx (mod) R2 stiff+ (can use Maitland symbols)
Muscle Length Tests (MLTs):
• Use objective measures (eg range in degrees, cm’s etc) where possible
• Document as “tight”, “very tight” or “lengthened” etc or use 0-3 rating scale (0=normal, 1=slightly tight,
2=moderately tight & 3=very tight)
• Comment on “resistance” during test (compared to unaffected side) especially if length is similar L to R
• Document any symptom response (location, severity, nature)
Motor Control (Specific Posture, Loading & Movement Control Tests) – also see Functional Tests above
• Document quality of movement
• Document any unhelpful pain behaviours
• Document symptom response (location, severity) & range or position of spine when symptoms occur
• Document any change in symptom response &/or performance if posture, movement or loading strategy is
altered

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Clinical Notes Summary & Template (2018)

Peripheral Assessment
Observations (Obs):
• Muscle tone, swelling, bruising, deformity, alignment, symmetry, scars etc
• Include provocative postures or positions
• Document any change in symptoms if posture or position is altered
Functional Tests (Fx’al Tests):
• Including tests of kinetic chain “capacity” & spring function (where relevant)
• Document quality of movement
• Document any unhelpful pain behaviours
• Document symptom response (location, severity) & range or position of joint when symptoms occur
• Document any change in symptom response &/or performance if movement or loading strategy is altered
Screening: Document what area(s) & with which tests
Physiological ROM (AROM & PROM including Combined Movements):
• Document joint and which movement planes were tested even if no symptom response (on initial
assessment)
o Full, pain free movement with over pressure = √√
• AROM - document quality of movement, range of onset of P1 (if relevant), range available (degrees),
symptom response (location & severity), limiting factor (R2 vs P2 or other) & response (including end feel)
with passive over pressure (if tested)
o Document any change in symptom response or range if movement strategy altered
• PROM – range of onset of P1 &/or R1 (if relevant), range available (degrees), symptom response (location &
severity), limiting factor (R2 vs P2 or other) & response (including end feel) with passive over pressure
• AROM/PROM findings can be combined in one section using a table:
(R) Knee AROM PROM
Flexion 110° Pk (mod) R2 ((L) = 130° R2) 115° Pk (mod) R2; firmer EF than (L) ((L) = 135° R2)
Extension -10° R2 ((L) = 0° R2) 0° R2; EF bony (quads lag of 10°) ((L) = 0° R2)

Passive Accessory Movements (PAMs):

• Document joint, position of joint (range), direction of glide (PA, AP, inferior, distraction etc)
• Document pain response (most important) – “the pain” reproduced?
• Document if glide feels normal, “stiff”/hypomobile/increased resistance to movement or hypermobile/less
resistance to movement & nature of the end feel
• Document limiting factor especially if P2 (R2 vs P2)
• Example: AP glide femur in -10° knee extension: hypomobile, no pain (R2)

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Clinical Notes Summary & Template (2018)

Muscle Tests: Resisted Isometric Muscle Tests:

• Document pain response (location, severity, “the pain”?) - most important
• Document strength (qualitative statement or Grade 0-5) – of secondary importance
MMTs/Tests of Muscle Strength &/or Endurance:
• Be specific – multi-joint vs single joint, concentric vs eccentric etc
• Document Grade 0-5, reps/sets until fatigue, load etc (as relevant)
(Muscle Tests may also be relevant to a spinal assessment)
Muscle Length Tests (MLTs): see above
Motor Control (Specific Posture, Loading & Movement Control Tests) - also see Functional Tests above: see above
Orthopaedic Tests:
• Document test performed & joint position
• There are numerous test names so, as an example, document “squat with tibial IR/ER” rather than “Ege’s
Test”
• Provide relevant detail ie don’t just state “positive” (see examples below)
• Ligament Stress Tests: document symptom response (pain, apprehension etc), laxity/increased movement,
end feel
• Meniscal Tests: document symptom response (pain, click etc)
Palpation:
• Be specific as to which structure or landmark (eg MCL not “medial knee”, medial head of gastrocs not “calf”)
• Document response – pain, increased tone, temperature etc
Neurological Exam (PNS & CNS, tests of central hypersensitivity): see above
NTPTs/Neurodynamic tests: see above

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Clinical Notes Summary & Template (2018)

Analysis
Diagnosis (Dx):
Stage & Progression:
Classification:
Key Contributing Factors (Problem List):
NOTE: Key contributing factors to the patients symptoms/loss of function should be listed (consider the
following areas: physical impairments (in addition to the classification), psychosocial factors (cognitive,
affective, social), unhelpful pain behavioural, work considerations, lifestyle considerations, whole person
considerations (GH & co-morbidities), extrinsic factors & underlying pathology considerations). Focus should
be on listing modifiable factors but non-modifiable factors can also be included. Try to order the list in order
of priority.
Short Term Goals:
Goals should be patient centred, specific, measurable & made at an activity/participation (functional) level.
Short term goals should be achievable in 2-3 visits. Use SMART format.
Long Term Goals: These goals guide discharge & should be written in the same format as short term goals.

Intervention/Treatment (Rx) & Evaluation

• Intervention/treatment/management performed at initial visit & the post Rx reassessment can all be
included in one section
• Document information provided to patient on diagnosis, contributing factors, treatment approach, prognosis
• Document all advice, education etc that has been provided
• Document informed consent when explicitly given & any warnings given to patient
• Ensure sufficient treatment detail so another therapist could replicate the same treatment
• Document all exercise parameters (reps, sets, rest periods, frequency), any warnings given & advice given
around self-modification of the exercise(s) or parameters
• Home exercise program (& advice) should be written out for the patient & photocopied; or can use pictures or
video
• Document scores of any Outcome Measures used (and keep completed questionnaire with the clinical notes)

Plan
In this section write what you plan on doing in the next visit or two (“as above” is not adequate). This may include
other assessments you wish to perform or a progression of treatment.

Sign off all entries with your name/signature & “Student Physiotherapist” (if UG or GEM)
or “Master of Musculoskeletal Physiotherapy Student”, Curtin University

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Clinical Notes Summary & Template (2018)

Follow Up Visits
Set up all your follow up visit entries in the following manner. Subjective & objective “comparable signs” should be
the focus of reassessment but there may be other information sought & other aspects of re-examination included.

S:

O:

A:

• Include a summary of patient progress… better, worse, same etc (brief statement)
• There is no need to re-restate the Diagnosis, Stage, Classification, Key Contributing Factors or Goals unless
these have changed (when taking over a patient from a previous student for the first time, it is usually worth
re-assessing the patient in a little more detail & documenting a “full” analysis section again)

I (or Rx) & E:

P:

Sign off all entries with your name/signature & “Student Physiotherapist” (if UG or GEM)
or “Master of Musculoskeletal Physiotherapy Student”, Curtin University