Physical Therapy Progress Note

Physical Therapy Progress Form - User Guide

Thank you for using our Physical Therapy Progress Form. This guide will help you understand how to effectively use all features of this digital form.

Overview

This form is designed for physical therapy professionals to document patient progress between evaluation sessions. It includes sections for patient information, subjective reporting, objective measurements, assessment, and treatment planning.

Form Sections

1. Patient Information

• Patient Name: Enter the full name of the patient
• Date of Birth: Select the patient's birth date
• Date of Evaluation: Select the initial evaluation date
• Date of Progress Note: Select the current session date
• Therapist: Enter your name as the treating therapist
• Clinic/Facility: Enter the name of your practice or facility

2. Subjective Information

• Patient Report/Comments: Document the patient's own description of their condition, including any changes they've noticed
• Progress Since Last Visit: Note improvements, regressions, or maintained status since the previous session
• Current Complaints/Pain Level: Record pain location, intensity (0-10 scale), and description

3. Objective Findings

This section includes three measurement tables:

Range of Motion (ROM) Table:

• Document joint movements being measured
• Record previous, current, and normal values for comparison

Manual Muscle Testing (MMT) Table:

• Track specific muscle or group strength
• Record previous, current measurements and goals

Functional Tests/Measures Table:

• Document standardized tests (like 6-Minute Walk or TUG Test)
• Track progress toward functional goals

Other Objective Findings:

• Add any additional observations not covered in the tables

4. Assessment

• Progress Status: Select whether the patient has improved, maintained, or declined
• Status Toward Goals: Describe how the patient is progressing toward established treatment goals
• Clinical Impression: Provide your professional assessment of the patient's condition

5. Plan

• Frequency/Duration: Specify treatment frequency (e.g., "2x/week for 4 weeks")
• Treatment Plan: Outline the proposed course of treatment
• Goals Revision: Modify existing goals or establish new ones as needed
• Recommendations: Include any additional recommendations for the patient or other providers

6. Therapist Signature

• Therapist Name: Enter your full name
• Date: Select the date of signing
• The signature line is provided for physical signing after printing

Using the Form

Digital Completion

1. Click or tap on any field to enter information
2. Use Tab key to move between fields efficiently
3. For date fields, use the date picker that appears when you select the field
4. For dropdown menus, click the arrow to view and select options

Printing the Form

• Click the "Print Form" button to generate a printer-friendly version
• The printed version will exclude the buttons and formatting not needed for physical copies
• After printing, physically sign the signature line

Resetting the Form

• Click the "Reset Form" button to clear all entered data
• This action cannot be undone, so ensure you've saved or printed needed information first

Tips for Effective Use

1. Complete all relevant fields to ensure comprehensive documentation
2. Be specific in your descriptions, especially for objective measurements
3. Use consistent terminology across sessions for accurate tracking
4. Update goals regularly to reflect patient progress
5. Print and sign the form after each session for proper documentation

Technical Notes

• This form works best in modern browsers (Chrome, Firefox, Safari, Edge)
• Form data is not automatically saved - consider printing or taking screenshots for your records
• The form is responsive and can be used on tablets and mobile devices

For questions or support, please contact your system administrator or technical support team.