Physiotherapist
Clinical Notes

Physiotherapist GLA:D® assessment Notes Template

Physiotherapist GLA:D® assessment notes document a patient's joint function, pain levels, and movement patterns as part of the Good Life with osteoArthritis in Denmark program designed to improve hip and knee osteoarthritis symptoms through neuromuscular education and exercise therapy.

These specialized records establish baseline measurements for joint range of motion, functional capacity, and pain severity while providing objective data for tracking patient progress throughout the GLA:D® intervention protocol.

They facilitate evidence-based clinical decision-making by identifying specific movement compensations, strength deficits, and functional limitations that guide personalized modifications to the standardized GLA:D® exercise program.

Why Are Physiotherapist GLA:D® Assessment Notes Important?

Comprehensive GLA:D® assessment notes enhance communication between physiotherapists, orthopedic specialists, and other members of the arthritis care team.

Properly documented GLA:D® assessments ensure compliance with clinical practice guidelines and physical therapy regulatory standards.

Detailed GLA:D® notes contribute to improved functional outcomes for patients with hip and knee osteoarthritis by establishing clear baselines and treatment progressions.

How to Write Physiotherapist GLA:D® Assessment Notes

Begin by documenting patient demographics, referral source, and specific osteoarthritis presentation in the initial assessment section.

Include standardized outcome measures such as the 40m walk test, 30-second chair stand test, and patient-reported outcome measures specific to the GLA:D® protocol.

Maintain objective language while clearly documenting functional limitations, pain levels, and movement patterns observed during the GLA:D® assessment process.

Key Components of Physiotherapist GLA:D® Assessment Notes

A comprehensive subjective history should include pain characteristics, functional limitations, prior interventions, and patient goals specific to osteoarthritis management.

The objective examination section documents range of motion, strength assessments, and functional testing results that will serve as baseline measures for the GLA:D® program.

The assessment and plan sections should avoid vague language and instead clearly connect clinical findings to specific GLA:D® exercise interventions and education components.

Tips for Writing Effective Physiotherapist GLA:D® Assessment Notes

Focus documentation on functional limitations and goals rather than exclusively on pain descriptions to maintain a client-centered approach aligned with GLA:D® principles.

Ensure patient privacy by following HIPAA and regional health information protection regulations when documenting and sharing GLA:D® assessment information.

Utilize digital GLA:D® templates that include drop-down menus for standard tests and measurements to streamline documentation while maintaining comprehensive records.

Automating Physiotherapist GLA:D® Assessment Notes

Implementing automated GLA:D® assessment templates can reduce documentation time by 40% while ensuring all required program elements are consistently captured.

Transition gradually by starting with hybrid documentation, where standardized GLA:D® outcome measures are automated while maintaining personalized narrative for individual patient presentations.

3 Common Questions About Physiotherapist GLA:D® Assessment Notes

How detailed should the initial GLA:D® assessment documentation be?

Initial GLA:D® assessments should comprehensively document baseline functional status using program-specific outcome measures, pain patterns, and activity limitations to effectively track progress throughout the program's duration.

How do I efficiently document reassessments for GLA:D® participants?

Use a side-by-side comparison format that clearly highlights changes in standardized outcome measures, functional status, and self-reported improvements to efficiently document progress through the GLA:D® program.

Are there specific documentation requirements for GLA:D® group sessions versus individual assessments?

While individual GLA:D® assessments require detailed patient-specific documentation, group session notes should focus on exercise progression, participant adherence, and any modifications made for specific participants within the standardized program.

Final Thoughts on Physiotherapist GLA:D® Assessment Notes

Well-documented GLA:D® assessment notes are essential for program fidelity, effective communication with referral sources, and demonstrating the evidence-based outcomes of this specialized osteoarthritis intervention.

Leveraging digital templates specific to the GLA:D® program can enhance documentation efficiency while ensuring all required elements are captured for program evaluation and patient progression.

GLA:D® Clinical Notes

Patient Information

  • Name: John Smith
  • Referral Source: Dr. Jane Doe, General Practitioner

Presenting Complaint

  • Chief Complaint Details:
    Persistent right knee pain with stiffness and difficulty in weight-bearing activities, consistent with symptoms of knee osteoarthritis (OA).

History of Presenting Condition

  • Timeline: Symptoms began approximately 2 years ago, progressively worsening over the last 6 months.
  • Symptoms: Morning stiffness lasting ~20 minutes, pain aggravated by walking and stair climbing.
  • Past Treatment: Physiotherapy sessions 1 year ago with limited improvement, intermittent use of over-the-counter pain relief.
  • Injury Mechanism: No recent trauma; gradual onset likely related to occupational strain.
  • Medical History: Hypertension, controlled with medication; no surgical history on the knee.
  • Subjective Information: Reports significant difficulty with household chores and gardening.
  • Personal/Social Context: Retired teacher; enjoys gardening and walking.
  • Occupation: Retired.
  • Hobbies: Gardening, reading.
  • Treatment Preferences: Prefers conservative management with minimal medication.

Aggravating Factors (Agg):

  • Walking for >10 minutes.
  • Climbing stairs.
  • Prolonged standing.

Easing Factors (Ease):

  • Resting with the knee elevated.
  • Warm compress application.

Red Flags:
None identified during assessment.

Medications:

  • Paracetamol as needed.
  • Amlodipine for hypertension.

Radiology and Pathology Results:

  • X-ray (6 months ago): Moderate joint space narrowing and osteophyte formation in the medial compartment of the right knee.

24-Hour Symptom Behavior:

  • Morning: Stiffness and mild pain (2/10).
  • Afternoon: Moderate pain (5-6/10) after activity.
  • Evening: Stiffness and soreness after prolonged sitting.

Patient Concerns:

  • Pain limiting walking and gardening.
  • Fear of requiring surgery.

Pain Levels:

  • VAS Scale: 6/10 (average daily pain).

Baseline Functional Assessment:

  • KOOS results: Pain 55/100, Symptoms 60/100, ADL 50/100, QoL 40/100.

Objective Measures Specific to OA:

  • Gait Analysis: Slight antalgic gait pattern on the right.
  • Joint ROM: Right knee flexion 110°, extension -5°; left knee WNL.
  • Muscle Strength: Quadriceps (R) 3/5, Hamstrings (R) 4/5.
  • Functional Tests:
    • Timed Up and Go (TUG): 12 seconds.
    • 30-Second Chair Stand Test: 8 repetitions.

Initial Examination:

  • Observations: Mild swelling around the right knee joint.
  • Functional Movement: Difficulty transitioning from sitting to standing.
  • ROM Tests: Restricted knee flexion with mild crepitus.
  • Motor Control: Decreased control during weight-bearing tasks.
  • Strength: Quadriceps weakness evident.
  • Neurological Assessment: Normal.
  • Posture: No significant deviations.

Clinical Impression:
Moderate knee osteoarthritis (right), impacting daily activities and quality of life.

Education Session Details:
Provided an overview of OA, emphasizing the importance of physical activity, weight management, and pacing activities to manage symptoms. Discussed the role of neuromuscular exercises in reducing pain and improving function.

Treatment:

  • Informed Consent: Obtained.
  • Manual Therapy: Soft tissue mobilization around the right knee.
  • Exercise Therapy: Initiated GLA® program, including neuromuscular and strengthening exercises tailored to the patient's needs.

Exercise Program Specifics:

  • Neuromuscular Exercises: Single-leg stance, balance board activities.
  • Strength Training:
    • Mini squats (10 reps, 2 sets).
    • Leg press (light resistance, 10 reps, 2 sets).
  • Frequency: 2-3 times per week.
  • Progression: Increase resistance and repetitions as tolerated.

Reassessment:
Plan to reassess in 6 weeks for progress in pain levels and functional outcomes.

Home Exercise Program:

  • Seated knee extensions (10 reps, 3 sets daily).
  • Standing leg raises (10 reps, 3 sets daily).

Goals:

  • Short-Term: Improve strength and reduce pain to allow for 15 minutes of uninterrupted walking.
  • Long-Term: Enhance knee function to enable participation in gardening and household tasks with minimal discomfort.

Next Appointment:

  • November 27, 2024, to review progress and adjust exercise program.

Quality of Life Measures:

  • Continue KOOS assessments at 3 and 12 months to monitor improvement.

Patient Education on Self-Management Strategies:

  • Encourage weight management through a balanced diet.
  • Activity pacing to avoid symptom flares.

Follow-Up and Outcomes Assessment:

  • Reassess functional performance and pain levels at 6 weeks, 3 months, and 12 months using KOOS and functional tests.

Additional Notes or Patient Concerns:
Patient expressed interest in group exercise sessions for OA management; will explore options for participation in the GLA

® program group classes.

Sincerely,
Jane Wilson, PT
Certified GLA

® Practitioner[Your Clinic's Name][Your Contact Information]