Analysis

The clear goal

This is potentially the most important legal note because this is the therapists professional opinion in light of subjective and objective findings. It should explain the reasoning behind all decisions taken and clarify and support the analytical thinking behind the problem-solving process. How you arrived at the stated goals should be indicated, as well as any factors that may require modification, such as frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:

The assessment is too vague e.g.
"Patient is improving"
Little insight is provided here!

Patient form

(from my own observations of my patient)

My assessment is:...

So, document the diagnosis you arrived at

include causes of the diagnosis

Red flag anything to be aware of (we need to treat patient holistically) note any inconsistencies

Proceed?

When you are ready, please proceed to the final Plan section for the needs of your patient.

Plan

(from all the observations of my patient):

The final component of the note is used to outline the plan for future sessions. The therapist should report on what the patient's Home exercises will be, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy are documented in this section.

Common errors:

The upcoming plan is not indicated.

Vague description of the plan e.g. "Continue treatment".

Patient Notes

Patient Name:...
Patient address & phone number:...
My patient needs to be referred to:...
I need to get an assistive aid (tripod, stick, crutches, heel raise etc):...
Next review date:...
I need to clinically review:...
I want to focus on treatment number:...

Essentially:

When is the next appointment

What will you do at that appointment

Any actions needed before the next appointment? (eg get crutches from next village)

might need a reminder system here for either a diary system or an 'alarm clock' signal when imminent also an onward referral or discharge tab(? )