Why a template, and why an evidence-based one
Every physio has a template in their head. The problem is that it changes with the day: by the fortieth patient the red flag questions are shorter, and two physios in the same clinic write two different kinds of note. A written template fixes both. Everyone asks the same screening questions, the notes read the same from one session to the next, and a colleague covering your patient finds what they need in seconds.
An evidence-based template goes further. The structure comes from published guidelines, so the note reminds you to screen for serious causes first, record a standard outcome measure, and write a plan the guidelines would agree with. It is a reminder, not a rulebook. Your clinical judgement still decides the treatment.
What every template has
Each assessment template has the same skeleton, so moving from one to another feels familiar:
- Subjective basics. History of the problem, pain now and at worst on a 0 to 10 scale, what it stops the patient doing, and their goals in their own words.
- Serious causes checked first. The red flags for that area as tick boxes, with a line on what a yes means.
- An outcome measure. A standard score you repeat, so progress is a number and not a feeling. Read outcome measures for why this matters.
- Plan basics. Your clinical impression, what you explained, treatment today, the home program, the expected number of sessions, and whether the patient needs a doctor, imaging or a specialist.
The templates, and what each is built on
- Low back pain assessment: NICE guideline NG59, and the STarT Back screening tool for risk.
- Neck pain assessment: the Canadian C-spine rule after an injury, and the Neck Disability Index.
- Shoulder pain assessment: the British Elbow and Shoulder Society pathways, and the SPADI score.
- Knee osteoarthritis assessment: NICE NG226, the OARSI 2019 guideline and the OARSI performance tests. A clinical diagnosis, without an X-ray for every knee.
- Ankle sprain assessment: the Ottawa ankle and foot rules first, then the 2018 international ankle sprain guideline.
- Total knee replacement review: NICE NG157, with wound and clot warning signs at the top.
- ACL reconstruction review: the Melbourne ACL Rehabilitation Guide 2.0, with criteria-based phases and the ACL-RSI.
- Falls risk assessment: the World Falls Guidelines 2022 and the CDC's STEADI tests.
- Stroke rehabilitation initial assessment: NICE guideline NG236 on stroke rehabilitation.
- Home visit note and video consultation: practical notes for treating outside the clinic.
All of them are on our resources page, where you can read each one fully before you use it.
Using them in Clinidiary
Open Settings, then Resources library, and press Add to my practice on the ones you want. Each becomes one of your own note templates. When you start a note, choose it and the sections are ready to fill. Your treatment notes save as you type, so nothing is lost when the phone rings.
If you work alone, these templates are the quickest way to write notes faster without cutting corners. If you see patients at home, use the assessment with the home visit note and read writing treatment notes between home visits.
Make them yours
These are starting points. Change the words to how you speak, add the special tests you use, and remove what you never fill. Two things are worth keeping however much you trim: the serious-cause screening, and one outcome measure you repeat. Those protect the patient and show the change.
Guidelines get updated too. Each template names its sources, so you can check you are using the current version.
Frequently asked questions
Are these physiotherapy note templates free?
Yes. You can read every template on our resources page, and add any of them to Clinidiary in one click.
Do I have to fill every question?
No. A template is a reminder. Skip what does not apply to the patient in front of you, and change the template to suit how you work.
Which guideline does each template follow?
Each template's page lists what it is built on, from NICE guidelines to the OARSI recommendations and the Melbourne ACL guide.
Can I change a template after adding it?
Yes. Once added it is your clinic's own copy, and your changes do not affect anyone else.