physio-progress-note

Physiotherapy Progress Note

Most progress notes record what was done to the patient. A funder, a colleague, and your future self all need something different: what changed, what it means, and why the plan is what it is now. A note that says 'continued as before' across six visits is what triggers a funding review, and deserves to.

What This Skill Produces

• Reassessment against the markers — the same measures from the initial assessment, so change is visible rather than asserted
• The interpretation — what the change, or its absence, means for the working hypothesis
• The plan change with its reason — including the deliberate decision to continue unchanged
• The objective-measure trend — numbers across visits rather than one snapshot
• Adherence, recorded factually — what the patient actually did, without blame
• The discharge trajectory — where this is heading and roughly when, which is what a funder is looking for

Required Inputs

Ask for these if not provided:

• The initial assessment markers — what was chosen to re-test, and the baseline values
• Today's findings — the same measures, plus anything new
• What the patient reports — function, symptoms, and what has changed in their week
• Adherence — what they actually did between visits
• The treatment given today — and, more importantly, the reason for it

Framework: Re-measure, Interpret, Then Change or Justify Not Changing

1. Re-test the markers you chose. The same measures, in the same way. Progress asserted without re-measurement is opinion.
2. Lead with function. What the patient can now do that they could not is the outcome; range of motion is a proxy for it.
3. Interpret, do not just record. Improvement consistent with the hypothesis strengthens it; no change after an adequate trial should challenge it. Say which.
4. Record adherence factually and without blame. 'Completed two of five sessions; work travel' is clinical information that explains the result.
5. State what the plan does next, and why. If it is unchanged, say why that is the right call — this is the sentence that answers a funding review.
6. Trend the numbers. A single value tells a reader nothing; three visits of the same measure tell them everything.
7. Name the discharge trajectory. Expected number of further visits and what discharge will look like. Treatment with no stated endpoint is what funders challenge.

Output Format

Progress note: [patient] · visit [n] · [date] · [clinician]

Subjective: [what the patient reports — function first, then symptoms] · Since last visit: [change, and anything new]

Adherence: [what was actually completed, and any reason given — recorded factually]

Reassessment against markers

| Marker | Baseline | Last visit | Today | Direction |

|---|---|---|---|---|

New findings: [anything not previously present]

Interpretation: [what the change or lack of it means for the working hypothesis — does it support, challenge, or require revision?]

Treatment today: [what was done] · Reason: [why this, now]

Plan: ☐ Continue unchanged — [why that is correct] ☐ Progress to [what] ☐ Regress to [what] ☐ Revise hypothesis — [to what, and what will test it] ☐ Onward referral — [to whom, why]

Discharge trajectory: [expected further visits] · Discharge will look like: [the criteria]

> A documentation framework for a licensed clinician. It does not diagnose, interpret findings, or determine appropriate treatment for any individual. Clinical reasoning and all decisions remain the treating clinician's, and record-keeping requirements follow your regulator's standards.

Quality Checks

• [ ] The same markers from the initial assessment were re-tested
• [ ] Function is reported before impairment measures
• [ ] The findings are interpreted against the working hypothesis, not just listed
• [ ] Adherence is recorded factually
• [ ] The plan states what changes and why, including a reasoned decision to continue
• [ ] Objective measures are shown as a trend across visits
• [ ] A discharge trajectory is stated

Anti-Patterns

• 'Continued as before.' The phrase most likely to trigger a funding review, and fairly.
• Recording treatment without reassessment. Documents attendance, not care.
• Listing findings without interpreting them. The reasoning is the note's only real content.
• Blaming the patient for adherence. Record the fact; it explains the result without judging.
• No change after six visits and no revised hypothesis. The plan should have changed, or the reasoning should say why not.
• Single-point measures. A reader cannot see a trajectory in one number.
• Never naming an endpoint. Open-ended treatment is what gets challenged.

Example Trigger Phrases

• "Write a progress note for a follow-up appointment"
• "The insurer is questioning continued treatment — what should my notes show?"
• "How do I document clinical reasoning in a progress note?"
• "My notes just list what I did — how do I improve them?"
• "Write a note where the patient has not improved"