Assess the Patient and Author a Treatment Plan

Once an episode has an owner, the clinical work begins. The physiotherapist first assesses the patient — what they report, what the examination finds — then turns that into a treatment plan with concrete SMART goals the course of therapy will work toward. These two steps move the episode forward and quietly raise the first charge.

Who / when: Tobi the physiotherapist does both, on the therapy detail screen, at the patient’s first physiotherapy attendance. A SMART goal is a goal that is Specific, Measurable, Achievable, Relevant and Time-bound — e.g. “Climb a flight of stairs unaided within 6 weeks.”

Record the assessment

1. Tobi — open the episode from Physiotherapy → Referral Worklist (click the row).
2. Tobi — in the Assessment block, press Add Assessment and record the findings: the Subjective (what the patient reports), the Objective (what the examination shows), a Pain Score from 0 to 10, and a Working Diagnosis. The fuller assessment also supports structured range-of-motion and muscle-strength (Oxford 0–5 grade) findings.
3. Tobi — Save Assessment. The episode advances from Referred to Assessed.

Note

Saving the assessment raises a PHYSIO-ASSESSMENT charge for the patient automatically — you do not type a charge by hand. It is captured once (idempotent), so re-editing the assessment will not bill it again. See How a Session Bills and Feeds Pulse.

Author the treatment plan and goals

1. Tobi — in the Treatment Plan & Goals block, press Author Plan.
2. Tobi — write the Problem List, then add the SMART Goals one by one. Each goal carries a description and a status (Not Started, In Progress, Achieved, Not Achieved, Discontinued). The fuller plan also records planned modalities (manual therapy, exercise therapy, electrotherapy, and so on) with a frequency and duration.
3. Tobi — Save Plan. The episode advances to Active — it is now under active treatment.

Tip

The plan is a full-set replace: when you save, the goals you see are the goals that stick. Revise the plan any time while the episode is open — edit a goal’s status as the patient progresses, add new goals, or remove ones that no longer apply.

The goal states feed the goal-attainment KPI in Veona Pulse, so keeping them current is what makes the rehabilitation-outcome analytics meaningful.

What happens next

With an active plan in place, the episode is ready for treatment. The next step is to schedule, deliver and sign the therapy sessions.

Follow the trail

• Previous: Receive a Chart Referral and Start a Physiotherapy Episode
• Next: Record and eSign a Therapy Session