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Obj: Visual
Obj: Testing
Obj: Palpation
Obj: Modalities



Treatment Plan

For all but the last session, include a "treatment plan" section

Under "Treatment Plan", record:

  •  each modality you are planning to use.

  •  the location where you are planning to use them

  •  the planned frequency of the sessions

  •  the duration of each modality

  •  and the purpose of the modality

Example: “30 minutes deep tissue massage, lower back, 2 times per week for 3 weeks, to decrease adhesion.”

Discharge Notes

For your patient's last session, include a "discharge notes" section instead of a "treatment plan".

Under "Discharge Notes" record:

  • a treatment summary (e.g., 12 sessions of deep tissue massage to the upper back)

  • your patient's current health status,

  • a summary of progress (most likely the same as the functional outcomes recorded under Assessment)

  • the reason for ending care (e.g., client met goal for care)

  • recommendations for ongoing care,

  • referrals


Use this section to record instructions, assignments and exercises given to the patient. Do not forget to be specific and provide detailed instructions to your clients.

Example: “Initiate stretching of back for 2 minutes every hour spent at the computer. Gave back stretching handout #3.”


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Next: Forms




Home | Introduction | Therapist| Client | Session | Subjective
Objective - Visual | Objective - Palpation | Objective - Modalities | Objective - Testing
Assessment | Plan | Forms

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Copyright © 2008 WinCity Custom Software, Inc.
Last modified: 10/15/08