7.Physio clinical note

What ACC Needs(physio)

What information should be included in an ACC record(Initial&follow up)+What good looks like(physio)

requirementsExample
Claim numberAB12345
Accident eventRolled ankle whilst out walking
Injury/DiagnosisR ankle sprain. (read code S550)
causation1 week ago rolled the ankle/acute injury.c/o minor swelling and pain.No previous problems.
If using time-based billing- the time taken to provide direct treatment*10mins cupping in the affected area.
*5mins Tuina in the affected area.
*45mins-acupuncture:
Ashi points,zulinqi,Xuan Zhong,yanglingquan+ashipoints around the yang chi(based on the balance method)
The heat lamp was applied in the locally affected area.
assessmentDescribe assessment findings
treatmenttreatment interventions
Effectiveness(What was the effect of the treatment?)What are you going to do next? Rv in 1 week is only part of the story.What are you going to review and how are you going to do this?Are you intending to progress/repeat treatment/HEP etc-if so how?
PlanWhat are you going to do next? Rv in 1 week is only part of the story.
What are you going to review and how are you going to do this?
Are you intending to progress/repeat treatment/HEP etc-if so how?
Goals/Outcome measuresThis helps us to understand how well the client is progressing

2nd follow-up visit

requirementsExample of physio’s clinical note
SubjectiveFeels as though there has been an improvement in her pain whilst walking. able to walk around 15mins prior to the onset of some pain.Not as swollen and not as stiff in the morning.
ObjectiveKnee to wall L=2cm,R=4cm.Swelling measured around malleoli L=20cm,R=22cm.Single leg balance eyes open L 40secs,R 20secs.Hop L full and pain free, R=full with pain on landing 4/10
TreatmentSoft tissue massage to foot/ankle/calf x 10mins,
seatbelt mobs into D/F grade 4.3 x 10.Checked HEP-progress balance
ex to eyes closed (ensure safe environment)attempt 3 x 30 secs.
Continue previous exs of knee-to-wall stretch and heel raises.
AnalysisProgressing as expected.KTW measured 2.5cm post-treatment with less pain on hop landing 2/10
PlanReview in 1 week.
Re-check Ox measures as above.
Repeat mobs if hasn’t achieved full ROM.
Check whether she has achieved the goal of walking for 30mins pain-free.
Discharge with further advice on self-management

What good looks like(physio)

Date15/02/2023
Claim numberXY00909
InjuryR MCL Sprain
Accident eventTwisted R knee during taekwondo
 S Feels each day his knee is improving,is limping a lot less when doing small steps,
still thinks it is partly a confidence issue with avoiding full extension.
Has had good adherence to exercises and feels his limping increases due to muscular fatigue.
Has also been incorporating stretches to ease into flexion and extension of the knee, and also found light traction of the knee quite easing.
He wanted to try taping tonight for his knee and discussed taping and injury recovery. 

O Grade 1 Effusion Minimal tenderness over mediolateral joint line
Tightness over medial R hamstring Mild tightness over R quad
Knee ROM Knee Flexion: R=130* L=145*
MMT Quad Strength L=5/5 R=4/5 no pain
Hamstring StrengthL=5/5R=4/5 no pain Rx TEVC.
STM Prone 10min-Hamstring Region
STM Supine5min – Knee Region
Knee Flexion Fulcrums x10 Grade 3/5
Passive Knee Extension Stretch x10 Grade 4/5

Education:
Discussion on taping vs brace and recovery.Discussed returning to taekwondo tonight to work on footwork,
advised to take it slow and avoid kicking movements,
discussed avoiding pivot movements for the time being. 

WG, VC, Rigid Taping Medial Knee
HEP: (Daily and as often as he can)-Terminal Knee
Extension Prone Lying 3×15 -Seated Leg Extension 3×20- Banded
SLR3x10-SL Glute Bridge 3×10 each 

A Knee Flexion 140 post tx.Tolerated session well.
Displays decreased self-efficacy in active movements and
feels that he will need taping and bracing when he returns to sport for confidence.