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Physiotherapy Clinical Notes
AI-assisted documentation system
Clinical Record
📋 Referral / Colleague Report
Paste one or more SOAP note summaries below (e.g. from previous sessions, or from the AI Clinical Summary / Quick Glance further down), then generate a concise written report suitable for a referring doctor or colleague.
Paste SOAP note summaries above, then click "Generate Report" to produce a referral-ready summary for a doctor or colleague.
Body Chart — Pain Mapping
▾
Anterior
Posterior
L. Lateral
R. Lateral
Mark Type
Pain (P)
Referred (R)
Numbness (N)
Pins & Needles
Stiffness (S)
Other (O)
Eraser
Select Body Area
Cervical Spine
Thoracic Spine
Lumbar Spine
Shoulder
Elbow
Wrist / Hand
Hip
Knee
Ankle / Foot
Visceral
Stecco FM
Women's Health
TMJ / Sinus
1 — Subjective / Present Illness(Cervical Spine)
▾
TxLxShTMJ
Patient Story / History in Own Words
Type freely or record the patient's story
Tap to select▾
Neck pain
Headache
Arm pain / radiculopathy
Dizziness
Stiffness
Post-whiplash
Post-surgical
⚠ Red Flags
Bilateral UL Sx
Bilateral LL Sx
Hand Clumsiness
Gait Disturbance
Recent Significant Trauma
Bowel/Bladder Dysfunction
Osteoporosis
Rheumatoid Arthritis
Long-term Corticosteroids
Unexplained Weight Loss
Hx of Cancer
Night Sweats
Night Pain (not relieved by rest)
Drop Attacks
Dizziness
Diplopia
Dysarthria
Dysphagia
Facial Numbness
Nystagmus
Nausea
Yellow Flags
Fear Avoidance
Catastrophizing
Work Dissatisfaction
Central Sensitisation
Sleep Disturbance
Ruminating
2 — Observation & Posture(Cervical Spine)
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TxLxShTMJ
3 — Physiological Movement (ROM) & Muscle Testing(Cervical Spine)
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TxLxShTMJ
Active ROM (% or degrees)
Passive ROM / End Feel
Effect of Repeated Movement
Isometric Testing
Muscle Length
Upper Trapezius
Levator Scapulae
SCM
Scalenes
Suboccipitals
Splenius Capitis
Semispinalis Capitis
Pectoralis Minor
Scapular Influence
MAP
4 — Palpation(Cervical Spine)
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TxViFMTMJ
PAIVM / Accessory Movement
Soft Tissue Palpation / Trigger Points
Upper trapezius
Levator scapulae
Suboccipitals
SCM
Scalenes
Splenius capitis
Splenius cervicis
Semispinalis capitis
Multifidus (Cx)
Deep neck flexors
Pectoralis minor
Rhomboids
Hypermobility
5 — Special Tests(Cervical Spine)
▾
TxSh
Cervical Radiculopathy
Upper Cervical Instability
VBI (Vertebrobasilar Insufficiency)
Cervicogenic Headache
UMNL (Upper Motor Neuron)
NeuroMeningeal
Cranial Nerves
6 — Neurological Assessment(Cervical Spine)
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Sh
Sensation / Dermatomes
Strength / Myotomes
Reflexes
Neurodynamics (ULTT)
7 — Outcome Measures & Diagnosis(Cervical Spine)
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8 — Treatment(Cervical Spine)
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TxLxShViFMTMJ
Manual Therapy — Mobilisations
AP MobilisationsAnterior-posterior▾
Unilateral AP Cx
Unilateral AP Tx
IV-Glide
Transverse glide
Longitudinal Mobilisations▾
Longitudinal cephalad
Longitudinal caudad
SNAGSustained natural apophyseal glide▾
Cx Flexion SNAG
Cx Extension SNAG
Cx Rotation SNAG (L)
Cx Rotation SNAG (R)
Reverse SNAG
1st Rib SNAG
Manual Traction▾
Sustained traction
Intermittent traction
Position of ease traction
Cx MaitlandMaitland accessory pressure▾
Grade I–II (pain)
Grade III–IV (stiffness)
Grade V (HVLAT)
Cx MAP▾
MAP 1st Rib
MAP C0/C1
MAP C1/C2
C2–C7 Up-slope
C2–C7 Down-slope
Segmental Traction
MAP C7/T1
Visceral ManipulationCervical referral patterns▾
Diaphragm release (C3–C5 phrenic nerve)
Pericardium / cardiac ligaments
Lung / pleura — upper lobe
Stomach fascial release (left Cx)
Liver / gallbladder release (right Cx)
Mediastinum release
Thyroid fascial release
Soft Tissue & Needling
STRxSoft tissue release▾
Upper trapezius
Levator scapulae
Suboccipitals
SCM
Scalenes
Posterior Cx muscles
Pectorals
Dry Needling (DN)▾
Upper trapezius
Levator scapulae
Suboccipitals
SCM
Splenius capitis
Semispinalis
Pterygoid
Masseter
Neural & Exercise
Nerve Mobilisation / Glides▾
Median nerve glide
Radial nerve glide
Ulnar nerve glide
Neural interface Cx
Exercise Programme▾
DNF training (deep neck flexors)
Scapular stabilisation
Cx ROM exercises
Cx strengthening
McKenzie extension
Postural correction
HEP issued
Pt Tailored
9 — Plan & Follow-Up(Cervical Spine)
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TxLxShViFM
Initial Plan
Follow-Up Sessions
No follow-up sessions recorded yet. Click “+ Add Session” above.
1 — Subjective / Present Illness(Thoracic Spine)
▾
CxLxVi
Patient Story / History in Own Words
Type freely or record the patient's story
Tap to select▾
Mid-back pain
Thoracic stiffness
Rib pain
Referred chest pain
Post-surgical
Postural pain
⚠ Red Flags
Unexplained Weight Loss
Night Pain
Hx of Cancer
Bowel/Bladder Dysfunction
Bilateral LL Sx
Chest Pain on Exertion
Osteoporosis / Fracture risk
Yellow Flags
Fear Avoidance
Catastrophizing
Work Dissatisfaction
Central Sensitisation
Sleep Disturbance
Ruminating
2 — Observation & Posture(Thoracic Spine)
▾
CxLx
3 — Physiological Movement (ROM) & Muscle Testing(Thoracic Spine)
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CxLxViFM
Muscle Length
Latissimus dorsi
Pectoralis major
MAP
4 — Palpation(Thoracic Spine)
▾
CxLxViFM
PAIVM / Accessory Movement
Soft Tissue Palpation / Trigger Points
Trapezius (mid)
Rhomboids
Erector spinae
Serratus anterior
Intercostals
Levator scapulae
Pectoralis major/minor
5 — Special Tests(Thoracic Spine)
▾
CxLx
6 — Neurological Assessment(Thoracic Spine)
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Sensation / Dermatomes
Strength / Myotomes
Reflexes
7 — Outcome Measures & Diagnosis(Thoracic Spine)
▾
8 — Treatment(Thoracic Spine)
▾
CxLxViFM
Manual Therapy — Mobilisations
Central PA MobilisationsThoracic▾
T1–T2 Central PA
T3–T4 Central PA
T5–T6 Central PA
T7–T8 Central PA
T9–T10 Central PA
T11–T12 Central PA
Grade I–II (pain)
Grade III–IV (stiffness)
Unilateral PA MobilisationsThoracic▾
Unilateral PA (L)
Unilateral PA (R)
Grade I–II
Grade III–IV
Rib Mobilisation▾
Rib PA mob
Rib rotation mob
1st rib mob
Rib HVLAT
Mulligan▾
Upper Tx SNAG
Mid Tx SNAG
Lower Tx SNAG
Side-lying Tx manipulation
Tx MAP▾
ERSR
ERSL
FRSR
FRSL
Neutral dysfunction
Diaphragm release
1st rib depressed (R)
1st rib depressed (L)
1st rib elevated (R)
1st rib elevated (L)
2nd rib up-slip (R)
2nd rib up-slip (L)
Ant. rib dysfunction (R)
Ant. rib dysfunction (L)
Post. rib dysfunction (R)
Post. rib dysfunction (L)
Abducted rib (R)
Abducted rib (L)
Adducted rib (R)
Adducted rib (L)
Ant. RRD (R)
Ant. RRD (L)
Post. RRD (R)
Post. RRD (L)
Visceral ManipulationThoracic referral patterns▾
Diaphragm — central tendon / costal
Lung / pleura — upper lobe
Lung / pleura — lower lobe
Pericardium / cardiac ligaments
Mediastinum release
Liver / gallbladder (right lower Tx)
Stomach (left lower Tx)
Oesophagus fascial release
Soft Tissue & Needling
STRxSoft tissue release▾
Trapezius (middle/lower)
Rhomboids
Erector spinae (Tx)
Latissimus dorsi
Serratus posterior
Intercostals
Dry Needling (DN)▾
Trapezius (middle)
Rhomboids
Erector spinae (Tx)
Multifidus (Tx)
Serratus posterior superior
Exercise & Rehabilitation
Exercise Programme▾
Thoracic extension over roll
Thoracic rotation exercises
Scapular retraction exercises
Posture correction
Breathing re-education
Rib mobility exercises
HEP issued
Pt Tailored
9 — Plan & Follow-Up(Thoracic Spine)
▾
CxLx
Initial Plan
Follow-Up Sessions
No follow-up sessions recorded yet. Click “+ Add Session” above.