Talk through the session. Vero logs it.
Vero Scribe writes the daily note in your template from the session conversation, with the patient’s consent, or from your dictation. You check the parameters and minutes, then copy it into your EMR.
Physical Therapy Daily Note Template
A physical therapy daily note, or treatment note, logs one session: what you did, with parameters and minutes, and how the patient responded. Copy the free template, see two filled examples, and check how much detail each intervention needs.
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- Word and text downloads
- Two filled examples
Blank physical therapy daily note template
FreePHYSICAL THERAPY DAILY NOTE Patient: [Name] Date of birth: [Date] Date of service: [Date] Visit: [Visit number, and visits planned] Time in and out: [Start and end times] Treatment diagnosis: [Condition and body region] Precautions: [Protocol limits, weight-bearing, vital sign limits, fall risk] Treated by: [Name, credentials; supervising therapist if an assistant treated] CHECK-IN Since last visit: [Pain out of 10, symptom change, new problems or falls] Home program: [How often done, any difficulty] Before treatment: [Vital signs if indicated, swelling, wound, readiness to take part] INTERVENTIONS Therapeutic exercise: [Exercise, sets and reps or time, load or resistance, minutes] Neuromuscular re-education: [Balance or motor control task, level, cues needed, minutes] Gait or functional training: [Task, device, distance or reps, assist level, minutes] Manual therapy: [Technique, region, grade or intensity, minutes] Modalities: [Type, settings, area, skin check after, minutes] Education: [Topic, method, how understanding was checked] Changes from last visit: [What was progressed, regressed, or added, and why] Total time: [Treatment minutes] RESPONSE During treatment: [Tolerance, pain change, vital sign response, cues or rests needed] End of session: [Pain, swelling, or skin after treatment; any adverse response] PROGRESS TOWARD GOALS Goal update: [Goals worked on today, today's result, on track or not] NEXT VISIT Plan: [What to progress, re-test, or check next time] Home program changes: [Exercises added or changed, dosage, written copy given] Communication: [Updates to the evaluating therapist, surgeon, or physician] Signed: [Clinician name, credentials, date and time]
Use it for
- Routine treatment visits
- Post-op rehab sessions
- Sessions led by assistants
- Home health visits
- Inpatient rehab
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Physical therapy daily note: 4 weeks after total knee replacement
Outpatient clinic, visit 7 of 16
Check-in
68-year-old woman, 4 weeks after a left total knee replacement; weight-bearing as tolerated. Pain 3/10 at rest, 5/10 after walking around the grocery store. Sleeping better, and the swelling is down since last week. Walks at home without the walker; uses a cane outside. Home program twice a day. No calf pain, fever, or wound drainage. BP 132/80, HR 74 before exercise.
Interventions
Recumbent bike, full revolutions, seat 1 notch lower than last visit, 8 min. Knee flexion stretch on a step 5 × 30 s and heel slides 2 × 15, 6 min. Sit to stand from a 46 cm (18 in) chair without armrests 3 × 8, and forward step-ups on a 10 cm (4 in) step 2 × 10, new today, 12 min. Gait training with a cane, 150 m (490 ft), cues for heel strike and knee extension, 6 min. Tibiofemoral and patellar mobilization into flexion, grade III, 8 min. Ice and elevation, 10 min. Total time 50 min.
Response
Knee flexion AROM 98° at the start and 104° after the bike and mobilization; extension lacks 5°. Pain up to 5/10 during the flexion stretch, 3/10 at the end. Two short rests during step-ups. No increase in swelling; skin intact after ice.
Progress toward goals
Goal 1, knee flexion 105° by week 6: on track. Goal 2, walk in the community with a cane: met on level ground; practicing curbs and ramps. Goal 3, stairs step-over-step with a rail: not yet, still step-to.
Next visit
Add lateral step-ups and bike resistance level 2; re-measure knee AROM. Home program: added heel raises 2 × 15 and step-ups on the bottom stair with the rail, once a day; written copy given. Keep the knee straight on a towel roll for 10 minutes twice a day. Call the surgeon’s office for calf pain or swelling, new redness or drainage at the wound, or fever.
Physical therapy daily note: neck pain with headaches
Outpatient clinic, visit 4 of 8
Check-in
34-year-old office worker with neck pain and cervicogenic headaches for 3 months. Headaches on 3 days this week, down from 5, peaking at 4/10, was 6/10. Neck pain 3/10. Raised her monitor at work. Doing chin nods and band rows most days. Denies dizziness, double vision, trouble speaking or swallowing, drop attacks, numbness, and arm weakness.
Interventions
Upper cervical mobilization, C1 to C2 rotation, grade III, both sides, 6 min. Thoracic mobilization, grade III, 4 min. Craniocervical flexion training with a pressure biofeedback unit, 10 × 10 s holds at 26 mmHg, up from 24 mmHg last visit, 8 min. Band rows with a green band 3 × 12 and prone Y raises 2 × 10, 12 min. Education on desk setup and a short break every 30 minutes, 5 min. Total time 35 min.
Response
Flexion-rotation test to the right 30° before and 38° after mobilization; left 42°. Cervical rotation right 62° before, 70° after. Held 26 mmHg for all 10 holds without substituting the superficial neck flexors. No headache during or after treatment. Neck pain 2/10 at the end.
Progress toward goals
Goal 1, headaches 2 days a week or fewer by visit 6: progressing. Goal 2, a full workday at the computer without a headache: progressing, 2 such days this week. Goal 3, independent with the home program: met.
Next visit
Re-test the flexion-rotation test and progress craniocervical flexion to 28 mmHg. Home program: chin nods 10 × 10 s twice a day; towel self-mobilization into rotation, 3 reps each side twice a day, new today; band rows 3 × 12 daily. Seek urgent care for a sudden severe headache, new dizziness, double vision, or trouble speaking.
What goes in each part.
Check-in
A short update before you start: what has changed since the last session, and whether it is safe to go ahead as planned.
- Pain out of 10 and any change in symptoms
- New problems, falls, or medication changes
- Home program adherence
- Vital signs or wound checks when the condition calls for them
Avoid: Repeating the full history. A line or two is enough unless something changed.
Interventions
The core of the daily note: each intervention, its dose, and its time, so the next clinician can repeat it or progress it.
- Sets, reps, load, or time for each exercise
- Device, distance, and assist level for gait and transfers
- Technique, region, and grade for manual therapy
- Settings, area, and skin check for modalities
- What changed from the last visit, and why
Avoid: “Continued exercises as before” without parameters. The next clinician can’t progress what isn’t recorded.
Response
How the patient tolerated the session, and what had changed by the end of it.
- Pain before, during, and after
- Vital sign response to exertion, when monitored
- Cues, help, or rest breaks needed
- Any adverse response, and what you did
Avoid: “Tolerated well” on its own. Say what was tolerated, and what limited the session if anything did.
Progress toward goals
One or two lines linking today’s session to the plan of care goals.
- The goal number or a short name
- Today’s result against it
- On track, ahead, or behind
Avoid: Leaving goals out until the progress report. A short line each visit shows why care continues.
Next visit
What you, or a colleague covering, should do next time, and what changed in the home program.
- The next progression or re-test
- Home program changes and dosage
- Who you updated, and about what
Avoid: “Progress as tolerated” with nothing named. Say what to progress.
Common mistakes, and how to avoid them.
Copying the last session forward
Identical daily notes suggest nothing was assessed or progressed. Record what changed, even if it was one parameter.
Exercises without parameters
An exercise without sets, reps, load, or time can’t be repeated or progressed by a colleague.
Minutes that don’t add up
Check that the minutes for each intervention match the total time and the time in and out.
No response recorded
Every session needs the patient’s response: pain, tolerance, vital signs if monitored, and any adverse event.
Assistant notes without the supervising therapist
When an assistant treats, name the supervising therapist and flag anything that needs their review, such as a new symptom or a missed goal.
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Frequently asked questions.
What is the difference between a PT daily note and a SOAP note?
Both record a visit. A daily note focuses on the session itself: interventions, parameters, minutes, and response. A SOAP note gives more room to measures, assessment, and plan, so many clinics use it for some visits and daily notes in between.
What should be in a physical therapy daily note?
The visit number and time, a short check-in, each intervention with its parameters and minutes, the patient’s response, progress toward goals, and the plan for next time.
How long should a PT daily note be?
Often half a page. Long enough that another clinician could run the next session from it, and that the reason for skilled care is clear.
Can a physical therapist assistant write the daily note?
In many settings, yes, within the rules of your regulator and the supervising therapist’s direction. The note should name the supervising therapist and flag anything that needs their review.
Is this physical therapy daily note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More physical therapy templates, and guides.
Physical therapy SOAP note template
Follow-up visit note with pain, ROM, MMT, special tests, timed interventions, and the home program.
Physical therapy evaluation template
Initial evaluation with history, systems review, tests and measures, prognosis, goals, and plan of care.
Physical therapy progress report template
Re-assessment with measures beside baseline, goal status, updated goals, and the case to continue.
Physical therapy discharge summary template
End-of-care summary with initial and final measures, goals met, the home program, and follow-up.
Vero for physical therapists
PT note examples, from daily treatment to discharge.
AI progress notes
Draft structured notes from the session, then edit and export them.
Progress notes guide
A step-by-step workflow, short examples, and a quality checklist.
Vero for physical therapy
Notes, documents, and follow-up in one workspace.
Common ICD-10 codes
The codes used most often in physical therapy.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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