Objective treatmentsAnalysis notes

 

First Aid

(text)

 

Neck and face

 

Face

(not sure how this is split with previous face/neck, so all in previous for now)

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Shoulder

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Elbow

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Hand and wrist

 

Hand

Positioning, stretching, functional activity, exercises, scar management, splinting

(not sure how this is split with previous hand/wrist, so all in previous for now)

 

Trunk and hip

 

Trunk back

(what is this page meant to hold?)

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Hip

(again, boundary with previous trunk and hip material still unclear.. left blank for now)

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Knee, ankle and foot

 

Ankle

(not sure how this is split with previous ankle/foot, so all in previous for now)

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Foot

(not sure how this is split with previous ankle/foot/toes, so all in previous for now)

Positioning, stretching, functional activity, exercises, scar management, splinting

 

Notes

What did you discover?

This is potentially the most important legal note because this is the therapists professional opinion in light of subjective and objective findings. It should explain the reasoning behind all decisions taken and clarify and support the analytical thinking behind the problem-solving process. How you arrived at the stated goals should be indicated, as well as any factors that may require modification, such as frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:

Essentially:

  • document the diagnosis you arrived at
  • include causes of the diagnosis
  • Red flag anything to be aware of (we need to treat patient holistically) note any inconsistencies