PSFS RECORD

Date: [Date]
Patient: [Name or ID, age]
Assessment point: [First visit, review number, or discharge]
Asked by: [Clinician who asked for or read back the activities; language and interpreter if used]

PROBLEM BEING RATED
Condition: [Diagnosis or main complaint, side if it applies, and date of onset or surgery]
Roles it affects: [Work, caring, sport, or hobbies the problem gets in the way of]

ACTIVITY RATINGS, 0 TO 10
Activity 1: [Activity in the patient's words; rating today; rating at the first visit]
Activity 2: [Activity in the patient's words; rating today; rating at the first visit]
Activity 3: [Activity in the patient's words; rating today; rating at the first visit]
Activity 4: [Activity and ratings, or not named]
Activity 5: [Activity and ratings, or not named]
Added since the first visit: [New activity with its first rating and date, or none]

AVERAGE
PSFS average today: [Sum of today's ratings divided by the number of activities, to one decimal]
Description: [Severe, moderate, or mild or no limitation]
First-visit average: [Date and average]

CHANGE SINCE THE FIRST VISIT
Each activity: [Points gained or lost; 3 or more on one activity is beyond measurement error]
Average: [Points gained or lost; 2 or more is beyond measurement error]
Exam beside the ratings: [Range, strength, or tests that agree or disagree with them]

TARGETS
Target per activity: [Rating aimed for on each activity, and by when]
Progress: [Met, getting there, or not met, for each target]

PLAN
Treatment focus: [What the next sessions work on, starting with the lowest-rated activity]
Next rating: [Date or visit for the next PSFS, with the same activities]

Clinician: [Name, credentials]