Physiotherapy session notes: what to write down and template to download

The session note is a brief record of each session. Kept regularly, it ensures the traceability of follow-up care, prepares intermediate assessments, and protects the practitioner.

This page details what it must contain, its place in the patient file, its difference from the BDK, and offers a ready-to-use template.

The session note in the patient file

The French National Authority for Health (HAS) recommends that all physiotherapists establish a file for each patient and keep it up to date. The file must be structured, clear, and make it possible at any time to know the treatments applied: this is the traceability and monitoring of care. In this regard, the HAS recommends keeping a "session log" for therapeutic follow-up.

What a session note must contain

1. Date, duration, and session number. Chronological reference and continuity.
2. Techniques and procedures performed. What was done during the session.
3. Clinical observations. Pain, mobility, strength, skin condition, exercise tolerance.
4. Progress. What is improving, plateauing, or regressing since the last session.
5. Adjustments. Modification of techniques, intensity, or frequency.
6. Home programme. Exercise programme provided or revised.

A brief but regular note is better than a follow-up reconstructed from memory; it is what feeds the intermediate assessment at the 30th session.

Session note or BDK?

These are two distinct documents:

• The physiotherapy diagnostic assessment (BDK) is the formal, billed document that establishes the diagnosis, objectives, and treatment plan, and is sent to the prescribing physician.
• The session note is the follow-up record, session after session, documenting execution and progress.

Regular notes greatly facilitate the writing of intermediate assessments (at the 30th session, then every 20 sessions).

Retention and confidentiality

Health data is kept in an active database for 5 years from the last intervention on the file, then archived (CNIL guidelines for the healthcare sector). The archiving period applicable to private practice should be confirmed based on your situation. During this period, access remains restricted to authorised persons.

Save time on your session notes

The obstacle is not the difficulty, but the repetition: one note per patient and per session, several times a day. Start with a fixed template, standardise your phrasing, and dictate the note right after the session.

This is what Delta does: you capture your observations via live note-taking or post-session dictation, and the tool generates a structured note based on your template, with a longitudinal patient memory that reuses the patient history from one session to the next, up to the intermediate assessment. HDS certified hosting, GDPR compliant.

Frequently asked questions