A physiotherapy procedure note template that sets out what belongs in each section, ready to adapt to your own clinic.
01Procedure note
TemplatePhysiotherapy
Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]
Physiotherapy procedure note, treatment session
1Indication
The problem being treated and the goal of the session.
2Consent
How consent was taken, and the risks, benefits and alternatives discussed.
Whether written consent is on the record, with its date.
3Procedure
Techniques used and the exercises taught, with sets and repetitions recorded.
Consent for any hands-on treatment.
4Findings
Response to treatment within the session, with any measurement retested.
5Complications
Any complication, or a record that there were none.
Anything that did not go to plan, and what was done about it.
6Aftercare and follow-up
Aftercare advice given, verbally and in writing.
Follow-up arranged, and what should prompt the patient to get in touch sooner.
How the Wai scribe fills it
The same note, written from an invented consultation.
Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.
01Procedure note
SignedAI-assisted, edited by the clinician
Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person
Physiotherapy procedure note
1Indication
Right patellar tendinopathy, session three. Goal is to progress loading.00:45
2Consent
Completed by the clinician from the record.
3Procedure
Progressive loading exercises taught, three sets of fifteen, recorded in the programme.03:30
4Findings
Single leg squat pain reduced within the session.07:15
5Complications
Completed by the clinician from the record.
6Aftercare and follow-up
Continue programme. Graded return to running. Review in one week.08:10
Questions
What goes in a physiotherapy procedure note?
Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for physiotherapy.
Is the worked example a real patient?
No. The consultation is invented for this page, and no real patient or record is used.
Does the scribe sign the note?
No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.
Can we use our own note structure?
Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.
