What ACC Needs(physio)
What information should be included in an ACC record(Initial&follow up)+What good looks like(physio)
requirements | Example |
Claim number | AB12345 |
Accident event | Rolled ankle whilst out walking |
Injury/Diagnosis | R ankle sprain. (read code S550) |
causation | 1 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. |
assessment | Describe assessment findings |
treatment | treatment 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? |
Plan | 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? |
Goals/Outcome measures | This helps us to understand how well the client is progressing |
2nd follow-up visit
requirements | Example of physio’s clinical note |
Subjective | Feels 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. |
Objective | Knee 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 |
Treatment | Soft 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. |
Analysis | Progressing as expected.KTW measured 2.5cm post-treatment with less pain on hop landing 2/10 |
Plan | Review 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)
Date | 15/02/2023 |
Claim number | XY00909 |
Injury | R MCL Sprain |
Accident event | Twisted 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. |