What physiotherapy documents

A physiotherapist (PT) evaluates and treats movement, mobility, and physical function. PT reports document:

• Current mobility capacity (walking distance, stability, gait pattern)
• Strength and endurance levels
• Balance and fall risk
• Pain that limits movement
• Progress or decline from previous assessments
• Recommendations for ongoing treatment or equipment

When PT reports are most useful

PT documentation is particularly relevant when:

• The person has had a recent fall or fracture
• There has been a stroke, neurological condition, or surgery affecting mobility
• The person is being assessed for wheelchair, walker, or other mobility aids
• You want to document that mobility has declined since the last CLSC assessment

Types of physiotherapy reports

Initial assessment report: Documents baseline mobility and functional status at the start of treatment.

Discharge report: Provided when PT treatment ends. Often documents whether goals were met and recommends any ongoing exercise, equipment, or follow-up.

Progress note: Issued during ongoing treatment; documents current status and trajectory.

For CLSC purposes, the most useful document is typically the most recent assessment or discharge report, as it reflects current capacity.

How to obtain PT reports

If physiotherapy was provided through the CLSC: The report may already be on file. Ask your care coordinator.

If treatment was done through a hospital rehabilitation program: Request a copy from the hospital's physiotherapy department or medical records.

If treatment was done privately: Ask the physiotherapy clinic directly. They should be able to provide you with a copy of the assessment or discharge summary.

What if physiotherapy hasn't been done?

If the person hasn't had a formal PT assessment, this doesn't have to be a gap in your documentation. Other evidence — a falls record, OT report, or physician note about mobility concerns — can serve similar purposes.

If mobility is a significant concern and no PT assessment exists, consider whether requesting a referral through the CLSC or a physician makes sense before the reassessment.

What should I gather next?

Return to the Medical Documentation Checklist for a full overview of documentation to prepare.