PHYSICAL 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]