Physiotherapy report templates: session, assessment, letter
Three blank physiotherapy report templates: the session note, the assessment and diagnosis, and the end-of-treatment letter to the doctor, with sources.
Physiotherapy report templates: session, assessment, letter
"Physiotherapy report" in fact means three documents, which have neither the same reader nor the same length: the session note, the physiotherapy assessment and diagnosis, and the end-of-treatment letter. Each has its own template. This article gives a blank template for all three and indicates where its structure comes from.
No patient case appears in it, real or invented: these are skeletons to copy and adapt.
Three documents, three readers
| Document | Who reads it | When | Where the structure comes from |
|---|---|---|---|
| Session report | You, and a colleague who might take over the follow-up | Throughout the treatment | Session log recommended by the ANAES (the former French national agency for accreditation and evaluation in healthcare), template extended by us |
| Physiotherapy assessment and diagnosis | The patient's file, and the prescribing doctor if you send them a diagnosis report | At the start of care | ANAES recommendation (published by the HAS, the French national health authority), March 2000 |
| End-of-treatment letter | The prescribing doctor and the primary care doctor | At the end of treatment | Letter outline from the same recommendation |
The three documents draw, to varying degrees, on the ANAES recommendation on the patient file in physiotherapy ("le dossier du patient en masso-kinésithérapie"), published by the HAS. It dates from March 2000: we use it as a reference for structure, without having checked it against more recent texts.
The session report
The session note keeps a record of progress between two sessions. It is best kept short: one heading, one idea. The ANAES recommendation advises keeping a session log and gives an example, which records for each session the date, the problems, the treatment, the techniques and the physiotherapist's signature. It does not offer an outline for a session report: the template below is inspired by this log and extends it. Adapt it to your practice.
SESSION REPORT
Patient: [surname, first name] · Date: [date] · Session no. [n] of [number prescribed]
Physiotherapist: [name]
1. PROGRESS SINCE THE PREVIOUS SESSION
Pain · functional difficulty · points reported by the patient
2. WORK CARRIED OUT
Techniques · exercises · parameters
3. CLINICAL OBSERVATIONS
Response to treatment · dated measurements · tolerance
4. PLANNED NEXT STEPS
Aim of the next session · instructions given to the patient
Physiotherapist's signature
The physiotherapy assessment and diagnosis
This is the best-regulated document. The ANAES recommendation lists ten headings for the patient file: social and administrative information, medical information, the patient's plan, physiotherapy examination, physiotherapy diagnosis, aims of care, treatment, results and evaluation, end-of-treatment report, professional correspondence. It classifies each item of data as "essential" or "preferable". The following template takes headings 2 to 7 for an assessment report.
One point of caution: the example layout that the recommendation offers in an appendix is given for guidance only, and the physiotherapist is invited to adapt the content to their activity. The list of data is the part to retain.
PHYSIOTHERAPY ASSESSMENT AND DIAGNOSIS REPORT
Patient: [surname, first name, date of birth, occupation] · Activities and sports practised: [list] · Date of assessment: [date]
Physiotherapist: [name] · Prescribing doctor: [name] · Prescription: [date, nature]
1. MEDICAL INFORMATION
Medical diagnosis · history of the condition · past history · tests · current treatments
2. THE PATIENT'S PLAN
Consent to care · plan of the patient or their relatives
3. PHYSIOTHERAPY EXAMINATION
Assessments carried out · tools used · dated results
4. PHYSIOTHERAPY DIAGNOSIS
Conclusion
5. AIMS OF CARE
Treatment aims and priorities · planned timeframes for achieving them
6. TREATMENT
Therapeutic, preventive and educational strategy
Example for a joint: an ankle assessment template produced by NeuroXtrain, to download (an 8-page PDF form, from the history to the summary). It covers the ankle and is not intended as a generic template: adapt yours to each region examined.
The end-of-treatment letter to the doctor
The same recommendation advises sending, at the end of treatment, a letter to the prescribing doctor and the primary care doctor together with the end-of-treatment report. It offers a letter outline, which the following template takes up heading by heading. The letter informs the doctor of the patient's condition at the end of treatment and, where relevant, justifies continuing the sessions.
[Prescribing doctor] · [address] [Physiotherapist] · [address, telephone]
Date: [dd/mm/yyyy]
Patient: [surname, first name]
Medical diagnosis: [title, date]
Reasons why the patient was referred to the physiotherapist: [one line]
Physiotherapy diagnosis: [a few lines]
Aims of treatment: [a few lines]
End-of-treatment examination: [a few lines]
Evaluation: physiotherapist's point of view · patient's point of view
Conclusion: after [n] sessions, [nothing to report · estimate of the need for further treatment · further tests]
Physiotherapist's signature
What makes a report readable
The recommendation asks that the file be structured, simple to use, and written in precise, clear language with an understandable vocabulary. Three habits follow for the report.
- One heading, one idea. The reader finds the information without rereading the document.
- Dated measurements and named tools. A result with no date or tool cannot be compared with that of the next assessment.
- A conclusion that stands alone. The prescribing doctor should be able to stop at the "physiotherapy diagnosis" or "conclusion" heading and understand the rest of the treatment.
When the tool holds the template
A blank template removes the blank page, it does not write anything. Markus starts from your dictation and writes the document in your template. You review and validate it, and the diagnosis and the decisions remain yours. The page Markus for physiotherapists presents the documents written for this profession.
Frequently asked questions
What is the difference between an assessment and a session report?
The assessment establishes the starting situation and concludes with a physiotherapy diagnosis, aims and a treatment. The session report follows progress between two sessions. The first is structured by the ANAES recommendation, the second is inspired by the session log that the same recommendation offers, and remains to be adapted.
Who should the end-of-treatment report be sent to?
The recommendation advises sending it to the prescribing doctor and the primary care doctor.
Can the same template be used for all patients?
Yes, that is the point of a template: it helps you not to forget anything. The headings stay the same, the content changes. The recommendation also invites the physiotherapist to adapt the file to their type of activity.
Further reading
- Ankle assessment: the clinical ankle assessment form (PDF, 8 pages), produced by NeuroXtrain.
- Markus for physiotherapists: the profession page.
- Official source: the patient file in physiotherapy ("le dossier du patient en masso-kinésithérapie") (ANAES, March 2000), published by the HAS.
