S
Subjective
Chief Complaint
Onset
Select onset
Sudden
Gradual
Duration
Select duration
Acute (< 6 weeks)
Subacute (6–12 weeks)
Chronic (> 12 weeks)
Progression
Select progression
Improving
Worsening
Fluctuating
Static
Pain Assessment
Pain Intensity (VAS)
0 - No Pain
0
/10
10 - Worst Pain
Pain Location
Select location
Lower back
Neck
Shoulder
Knee
Hip
Other↓
Side
Select side
Right
Left
Bilateral
Pain Radiating?
No
Yes↓
Radiating Side
Right
Left
Radiating Sites
Thigh
Knee
Leg
Foot
Big toe
Other↓
Aggravating Factors
Walking
Standing
Climbing stairs
Lifting
Prolonged sitting
Relieving Factors
Rest
Medication
Ice/Cold
Heat
Position change
Past Medical History
Hypertension
Diabetes
Cardiovascular Disease
Respiratory Condition
Surgical History
Yes↓
No
Select side
Right
Left
Bilateral
Weeks
Months
Years
Next surgeon Visit
Affected Activities
Walking
Standing
Climbing stairs
Lifting
Prolonged sitting
Mechanism of Injury
Fall
Road Traffic Accident
Sports
Lifting
Twisting
No specific injury
Brace / Support Used
Back Support
Knee Support
Ankle Support
Wrist Support
Elbow Support
Cervical Collar
AFO
Cock-Up Splint
Knee Immobilizer
Abduction Sling
Additional Subjective Notes
O
Objective
Observation
Posture
Select posture
Normal
Forward head
Kyphotic
Lordotic
Sway back
Other↓
Gait
Select gait pattern
Normal
Antalgic
Ataxic
Trendelenburg
Shuffling
Other↓
Assistive Device
Select device
None
Cane
Walker
Crutches
Wheelchair
Other↓
Sensation
Select sensation
Intact
Impaired
Absent
Swelling
No swelling
Mild
Moderate
Severe
Palpation - Tenderness
No tenderness
Grade 1 (Painful on deep pressure)
Grade 2 (Painful on moderate pressure)
Grade 3 (Painful on light pressure)
Grade 4 (Withdrawal/guarding)
Range of Motion (ROM)
Side
Joint
Movement
Result
Degrees
--
R
L
B/L
--
WNL
Limited
Add ROM Row
Manual Muscle Testing (MMT)
Side
Muscle
Grade (0-5)
--
R
L
B/L
Add MMT Row
Special Tests
Side
Test Name
Result
--
R
L
B/L
--
Positive
Negative
Other
Add Special Test
Other Objective Notes
A
Assessment
Diagnosis
Problem List
Muscle weakness
Limited ROM
Balance deficit
Poor motor control
Functional limitation
Pain
Balance
Good
Fair
Poor
CT / MRI Findings
Date of Imaging Report
Referring Doctor
Goals
Reduce Pain
Improve ROM
Improve Muscle Power
Improve Endurance
Improve Balance
Restore Functional Activity
Prognosis
Excellent
Good
Fair
Poor
P
Plan
Modalities
TENS
IFC
Ultrasound
Hot Packs
Cold Packs
Shockwave
Galvanic
Faradic
TENS + Suction
IFC + Suction
Therapeutic Exercises
Strengthening
Stretching
ROM
Balance training
Functional exercises
Isometric
Home Program
Total Sessions
Frequency
Full SOAP Note Report
Edit Report
Save Progress
Copy Report
Reset Form
Exercise Selection
Search Exercises
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2
Filter by Category
All Categories
ROM
Stretching
Strengthening
Balance
Gait Training
Neuromuscular
Functional
Postural
Endurance
Flexibility
Device-Based
Filter by Region
All Regions
Neck
Shoulder
Elbow
Wrist
Hand
Back
Hip
Knee
Ankle
Foot
Core
Spine
Full Body
Set Parameters for Selected Exercises
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Progress Note
Progress Note Documentation
Physiotherapy Session #
S
Patient Said
Add
Patient Statement
Complaints
Pain
Swelling
Stiffness
Fatigue
No complaints
Self-reported Progress
Improved
No change
Worse
HEP Performance
Completed
Partially done
Not done
O
What Was Done
Selected Exercises:
Selected Modalities:
Electrotherapy
Exercise
Measurements
Add Measurement
A
Therapist Observations
Add
Patient was delayed
Delay duration:
minutes
Clinical Observation
Observations
Good performance and technique
Dependent on therapist support
Pain or discomfort during activity
Functional gains observed
P
Plan for Next Session
Add Plan
Plan Summary
Plan Details
Continue current program
Progress to advanced exercises
Re-assessment planned
PMR consultation
Start gym-based exercises
Begin gait training
Wean off assistive device
Discontinue support device
Modify home program (HEP)
Stop electrotherapy
Prepare for discharge
Last session / discharge
Distribution
Enable Distribution
Transfer To
Reason
Loaded schedule
Vacation
Department rotation
Estimated Return
Days
Weeks
Expected Return Date
Transfer Type
Temporary
Full transfer
Additional Notes
D/C
Discharge Summary
Enable Discharge
Number of Completed Sessions
Overall Improvement
%
Final Measurements
VAS:
ROM:
MMT:
Special:
Other:
Reason for Discharge
Completed plan
Goals achieved
Referred out
Non-compliant
LAMA
Other
Discharge Notes
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Progress Note Narrative
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Electrotherapy & Modalities
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2
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modalities selected
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