Physiotherapy treatment chart: what to record, section by section

A treatment chart is the document that tells the next therapist, the patient and, sometimes, an insurer or a court what you did and why. A good one can be read in a minute by somebody who has never met the patient. This is what belongs in each section, in the order most Indian clinics use, with notes on what makes each part useful.

1. Patient details

• full name, age or date of birth, gender

• mobile number

• referring doctor, if any

• date of first visit

• patient ID, so the chart cannot be confused with someone else's

Keep this short. The chart is for treatment; the full contact record lives elsewhere.

2. Chief complaints and history

Write the complaint in the patient's own words first ("pain on the outside of the right knee going downstairs, 3 weeks"), then the history: onset, mechanism of injury, how it has changed, what makes it better or worse, previous treatment, relevant medical history and medicines. Note red flags you asked about and the answers, even when they are negative. "No night pain, no weight loss, no bladder or bowel change" is useful later.

3. On examination

Record what you found, with numbers wherever you can:

• Observation: posture, swelling, wasting, gait.

• Range of motion: active and passive, in degrees, with the side.

• Muscle power: graded, for the muscles that matter to the complaint.

• Special tests: name the test and the result, positive or negative.

• Neurological findings: where relevant, sensation, reflexes and power by level.

"Knee flexion 95 degrees active, 110 passive, pain at end range" is a finding. "Reduced ROM" is not.

4. Pain scale

Use one scale and keep using it. A visual analogue or numeric scale from 0 (no pain) to 10 (worst imaginable) is the most common. Record pain at rest and on the aggravating activity separately, because they often move differently.

5. Provisional diagnosis

Your working diagnosis, written plainly, and the doctor's diagnosis if the patient was referred with one. It can be changed later; record the change rather than overwriting it.

6. Treatment plan and modalities

List what you plan to give and why:

• electrotherapy, such as IFT, TENS, ultrasound, SWD or muscle stimulation, with parameters if your clinic records them

• manual therapy and mobilisation

• traction, taping, dry needling, heat or cold where used

• exercises, with sets, repetitions and frequency

• advice and education, such as posture, activity changes and home care

Set a goal you can check: "climb one flight of stairs without pain in 3 weeks" tells you and the patient when the plan is working.

7. Session log

For every visit, a line or two: date, what was given, how the patient responded, and anything changed. This is the part most often left blank on paper charts, and the part an insurer or a covering colleague most needs.

8. Review and outcome

At set points, repeat the measures you recorded at the start (pain, range, function) and write whether the patient has improved. At discharge, record the outcome and the advice given.

9. Signature

The treating physiotherapist's name, qualification and registration number, signed and dated.

Keeping the chart in PhysioDesk

The same sections live on the patient's record in PhysioDesk, so nothing has to be copied from paper:

• Patient details are entered once at enrolment.

• Diagnoses hold what you are treating, each with its own sessions.

• Every session has a SOAP note: subjective (the complaint), objective (your findings), assessment and plan, signed by the therapist with the time.

• Progress measures such as pain score and range of motion are recorded on a date and charted across the course.

• Exercises are prescribed from your library and appear on the patient's phone.

• Bills can list every session date and include a certificate of treatment for the patient's insurer.

• Change history shows who changed which detail, and when.

You can see all of it in the 30-minute demo on the pricing page.