Example of Abrreviated Clinical Narrative Notes for Physical Rehabilitative Documentation

These are Excerpted notes from the Chart of a 73 year-old male patient.

Chief complaint(s):
Left knee weakness and pain
Left foot pain
Right shoulder pain

#1: Left Knee pain: Pain and functional evaluation:
Left knee with grade 5/10 continuous aching to cramping pain with marked on standing and extended weight-bearing to personal grade of 5-6/10. Pain alternates and is often accompanied by local numbness. In local jargon, pain was described as accompanied by “ngimay.” Home and recreational activities are limited by ambulatory restrictions dictated by left knee weakness, pain, and instability. Instability and weakness at left knee currently pre-dominate pain at the left knee as chief complaint.

Going up a flight of stairs is the activity most limited by knee disability, with going down the flight of stairs a close second on scale of difficulty. Movement on even terrain with plus one minimal assist or staff cane over 5 meters is now tolerable. Patient declares that all activities are affected, with strenuous activities impossible to perform.
With regard compensatory activity related to ambulation, the patient notes (1) frequent rests during the activity, (2) purposeful avoidance aggravating activities (such as purposeful avoidance stair-climbing), and constant requests for mild to moderate assistance to perform and complete ambulation. Toiletry is accomplished slowly sans assistance. Bathing and dressing require assistance.

Left knee pain was first noted at left knee from eight years prior, graded at PS 3-4/10.
Starting point with marked pain exacerbation and functional limitation at three years prior was inability to weight-bear at left knee, and inability to ambulate sans +1 moderate assist plus staff cane. Pain at time of severe exacerbations at one and two years prior peaked at personal grade 10/10, with inability to weight-bear at left knee unless aided with +1 moderate assist plus staff cane on contralateral extremity. Some relief from pain was afforded post local steroid infiltration and hyaluronic acid infiltration.


Our patient is currently undergoing physical rehabilitation, with particular focus on manipulative / manual medicine techniques for decreasing pain, improving muscle strength, and improving soft tissue compliance. Myofascial compliance is maximized at each treatment session. Physical rehabilitation has progressed functional use of knee to unaided weight bearing to 3-5 meters before balance is lost due to weakness and instability at the left knee. Additional treatments incorporated have included Psychotherapy, Medical Hypnosis, Acupuncture, and Osteopathic Manipulative Techniques.

Problem #2: Right shoulder pain and limitation of movement:
Pre-treatment: Today’s Range of motion testing
Active Passive left Shoulder right active Passive
160 130 Flexion 0-180 115 95
60 70 Extension 180 40 70
70 85 Abduction 0-90 60 85
8 10 Adduction 90 10 15
50 55 Internal Rotation 0-90 45 50
65 70 External Rotation 90 65 70

/Sandro Strix S. Toledo, M.D., DHP, DNLP, DMS