Effective clinical documentation is crucial for physiotherapists to track patient progress, communicate with other healthcare professionals, and ensure continuity of care. A well-structured progress note typically follows the SOAP (Subjective, Objective, Assessment, Plan) format. Here’s a detailed walkthrough on how to create a comprehensive physio progress note using this format.

Subjective Section

Start by recording the History of Present Condition. This includes the patient’s main complaints, onset, and history of the condition. For example, "The patient, a 45-year-old male, presents with a primary complaint of lower back pain, which began after lifting a heavy object at work two weeks ago. The pain has progressively worsened, radiating to the left leg, and is described as a sharp, shooting pain. The patient reports difficulty in performing daily activities and has a history of sedentary lifestyle."

Objective Section

Document the findings from the physical examination. Include measurable data and any tests conducted. For instance, "Physical examination reveals tenderness in the lumbar region with limited range of motion in the lower back. Observations include a positive straight leg raise test on the left side. Specific measurements show reduced lumbar flexion and extension. Blood pressure is 120/80 mmHg. MRI results indicate a herniated disc at L4-L5."

Assessment Section

Provide your professional interpretation of the findings. State the diagnosis and any changes in the patient’s condition. An example would be, "Based on the subjective and objective findings, the therapist concludes that the patient is experiencing lumbar radiculopathy due to a herniated disc. There has been minimal progress in pain reduction, necessitating a modification in the treatment plan."

Plan Section

Outline the treatment plan and any patient education provided. Specify the interventions and frequency. For example, "Treatment plan includes manual therapy, core strengthening exercises, and postural training, with sessions twice a week for six weeks. Patient educated on proper lifting techniques, importance of regular exercise, posture correction, and use of lumbar support belt."

Documenting patient interactions can be time-consuming for physiotherapists, detracting from valuable patient care time. This is where AI medical scribes, like Notis AI Medical Scribe, come into play, offering a transformative solution for the physiotherapy specialty.

Advantages of Notis AI Medical Scribe

Notis AI Medical Scribe significantly reduces the time spent on patient documentation. Leveraging advanced voice-to-text technology, Notis transcribes patient interactions into structured SOAP notes, enabling physiotherapists to focus more on patient care rather than administrative tasks. With an impressive 99% accuracy, the platform ensures high-quality medical notes, facilitating better patient outcomes.

Notis offers a seamless integration with familiar tools like WhatsApp, eliminating the need for additional software and making it exceptionally user-friendly. The ability to work in multiple languages and retrieve patient information using natural language queries further enhances its usability. By saving up to 2 hours per day, Notis helps physiotherapists increase productivity and reduce burnout, ultimately improving patient care and satisfaction.

By incorporating AI medical scribes into their practice, physiotherapists can streamline the documentation process, ensuring that every patient interaction is accurately captured and easily accessible. This technological advancement not only improves operational efficiency but also enhances the quality of patient care.