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Clinical

Physiotherapy

An assessment with range of motion in degrees, active and passive, against the normal for each joint and movement; muscle power on the MRC 0–5 scale; a session plan; and sessions recording modalities, pain before and after, and a progress note — so progress is a chart.

For:PhysiotherapistsRehabilitation physicians

Where:on the visit: New assessment · Clinical › Physiotherapy · Configuration › Joints & Movements

How to

Assess a patient

  1. On the visit, New physiotherapy assessment: kind (initial, review, discharge), presenting problem, onset, pain score and site, function score, goals and plan, sessions planned.
  2. Range of motion › Add: the movement (joint proposed), side, active and passive degrees; the normal, the deficit and the percentage compute; tick painful, note the end feel.
  3. Muscle power › Add: muscle group, side, MRC grade.

Record a session

  1. Add a session: date, therapist, duration, the modalities used (exercise, manual therapy, TENS, ultrasound, interferential, hot and cold packs, traction, taping, hydrotherapy, gait, balance), exercises and technique, pain before and after, the progress note.
  2. Tick Charged when the session is billed; the count of sessions shows on the assessment.

Close the episode

  1. Complete the assessment: the limited movements are summarised on the visit’s chatter.
  2. A review assessment repeats the measurements and shows the change.

See also: Visits (EMR) Bills, Charges & Cashier