Objective treatmentsAnalysis notes

 

First Aid

(text)

 

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

 

Neck and face

 

Face

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

 

Trunk and hip

 

Hip

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

 

Knee, ankle and foot

 

Ankle

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

 

Foot

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