It's a Tuesday afternoon. Daniel is twelve minutes into a follow-up with a runner he's been seeing for a chronic Achilles. Visit three. The patient is sitting on the edge of the plinth, socks half-pulled down, ready to be told what to do next.
Daniel asks the question every physio asks at the start of every follow-up: "How did the exercises go?"
The runner shrugs. "Yeah, I did them. They were fine."
Daniel nods. He looks at his note from visit one. It says "HEP given — eccentric calf, isometric hold, single-leg balance." No reps. No sets. No tempo. No load. He cannot remember if he told the patient to do the heel drops on a step or on the floor, and whether the isometric was a 30-second hold at 70% or a 45-second hold at 100%. He cannot remember whether the single-leg balance was eyes open or eyes closed. He wrote the note at 6:45 p.m. last Tuesday, between two SOAP notes for patients he'd already half-forgotten.
The runner is waiting. Daniel makes a decision the way most of us make it in that situation: he assumes the patient did something roughly like what he meant, and he progresses the plan. The visit moves on.
What's Actually Happening
This is not an adherence problem. It is a traceability problem, and it sits one step upstream of the adherence question. Before a physio can ask "did the patient do the exercises", they need to be able to answer "what exactly did I prescribe last time?" If that part is fuzzy, the whole follow-up loop collapses into a polite shrug between two people who both want the visit to go well.
The home exercise program is the part of the case the patient takes home. In a well-run case it carries:
- Exercise selection — which exercises, in which order, with which progressions queued up for the next visit. The APTA's Guide to Physical Therapist Practice and World Physiotherapy both treat the HEP as a clinical intervention, not a handout — meaning the prescription itself is part of the chart.
- Dose — sets, reps, tempo, load, frequency, rest. The clinically meaningful difference between an Alfredson eccentric calf protocol (3×15, twice daily, with load) and "some heel drops at home" is the dose. The note that says "HEP given" doesn't tell you which one.
- Cueing and form — knee tracking, hip stack, breath, pain rule (e.g. the Silbernagel 0–5 pain monitoring model for tendinopathy). These are the parts that fall off a printed handout and the parts the patient misremembers within twenty-four hours.
- Baseline against which to compare — the outcome measure the physio took on visit one (NPRS for pain, PSFS for function, ROM in degrees, a single-leg hop distance) so that at visit three "how did it go" has a number to land on instead of a shrug.
- Promises and modifications — "we'll add the hop progression once the heel drops are pain-free at 3/10", "swap the single-leg balance for tandem stance if the Achilles flares". These are the moments the physio remembers as concepts and the patient remembers as nothing.
A handout carries some of this. The chart usually doesn't. And seven days later the physio is the one across the plinth who needs to remember it — because the patient won't.
Other Physios Saying The Same Thing
This is not Daniel's problem. It is a structural problem in the way outpatient physiotherapy is documented in a thirty-minute slot. Adam Richmond, an osteopath writing on his own clinic blog in "I love it when the exercises don't work!" (July 22, 2022), put the upstream problem in one line:
"Exercise compliance eg getting a patient to do the damned exercises!"
— Adam Richmond, Osteopath, painman.co.uk, July 22, 2022
Richmond's broader point is that when a patient comes back and says the exercises didn't work, the only way to act on that honestly is to know what the patient was actually meant to do. Otherwise "didn't work" is indistinguishable from "didn't do", and the next prescription is built on a guess.
Ameeth Ruparelia, Senior Physiotherapist at Scarborough Physio and Health, writing in "Why don't people do their physio exercises? Part 1", named two of the working numbers every outpatient physio carries in their head:
"Most patients do not do their exercises as prescribed… Evidence suggests that patients may only retain as little as 20% of everything that is discussed in a consultation after 24 hours."
— Ameeth Ruparelia, Senior Physio, Physio Redcliffe blog
Twenty percent retention after twenty-four hours is the part most physios have already accepted about their patients. The part that gets less airtime is the equivalent number on the clinician's side: how much of what we prescribed do we remember a week later, with thirty patients in between, if it isn't written down with the texture it had in the room?
Gell and colleagues, in a 2024 qualitative study in PTJ / PubMed Central on physical therapists' use of mobile technology for HEPs in arthritis, interviewed working PTs and got the part out loud that doesn't usually make it into a chart audit:
"I don't take the time to dive into patient feedback on exercise compliance, and it's nice to have those features automatically pop up."
— Physical Therapist 11, Gell et al., PMC11006223, 2024
"I guess I always really want to know if there are certain ones or one that was too hard."
— Physical Therapist 7, Gell et al., PMC11006223, 2024
The pattern across two decades and three voices is consistent: the physio wants to know which exercise the patient struggled with, which one they skipped, and which one is ready to progress. None of that is answerable if the prescription itself is sitting in last Tuesday's "HEP given" note.
Why The Note Loses
Every physio knows the HEP note should be longer. The problem is that the visit ends with the patient still tying their shoelaces, the next patient already in reception, and the clinician trying to demonstrate one more rep at the door. The detail of the prescription — the tempo, the cue, the progression rule — gets said out loud and then has to be reconstructed at the workstation between rooms, or after 7 p.m., or on the train home.
By the time the chart gets written, the texture is gone. The physio can remember the broad strokes (eccentric calf, isometric hold) and very little of what made the prescription patient-specific (the cue about the dropped pelvis, the rule that pain above 4/10 means stop). The texture is the part the follow-up depends on.
The blocker is the tool. If detailed HEP charting means walking to the workstation, opening the EMR, finding the patient, clicking into the right encounter, and typing — the texture loses every time. Especially with thirteen patients still on the column.
Where Dr. Notes Fits
Dr. Notes won't make the visit longer or the patient more adherent. But it changes where the prescription lives, so the next follow-up isn't a memory test.
Three things matter for an outpatient physio chair:
- Capture the HEP in the patient's voice, while you're still saying it. Dr. Notes has voice-to-text on the patient's record. Daniel can say "3 by 15 eccentric heel drops off a step, slow eccentric over 3 seconds, pain rule 0 to 4 out of 10, twice daily; 45-second isometric plantarflexion hold against the wall, three rounds, once daily; single-leg balance eyes open 30 seconds each side" — and the prescription is in the chart before the patient has their shoes back on. No workstation. No retyping at 7 p.m.
- Pull up last visit's prescription in two taps at the start of follow-up. Visit history sits on the patient's profile. When Daniel opens the runner at the start of visit three, the visit-one note is already on screen — including the exact dose, the cue, and the pain rule. The question "how did the exercises go" now has something specific to compare against, instead of a shrug.
- Attach a short demo video to the patient's record. Dr. Notes lets you add images and short videos to a note. A 15-second clip of the patient doing the eccentric heel drop correctly, taken on the phone in the room, is worth more than a paragraph of cueing. At visit three it tells Daniel — and the patient — exactly what was prescribed and exactly how it should look.
- It works offline, in a living room. Home-visit PTs already know this part. Dr. Notes is local on the device, so the prescription gets written on the patient's sofa, not retyped at the clinic the next morning.
- Follow-up reminders are tied to the patient, not your inbox. The recall fires at the interval you set when you set it — so the HEP review happens at the visit it was meant to happen at, not when you happen to remember.
None of this changes what a physio prescribes. It changes whether the prescription is still legible to the prescriber seven days later, with thirty patients in between.
The Tuesday-Afternoon Version
Twelve weeks from now, the runner is back. Daniel opens the patient. The visit-one note still says what it said: 3×15 eccentric heel drops off a step, 45-second isometric, single-leg balance eyes open. The video of the eccentric is still attached. The progression rule is still there.
Daniel asks the question every physio asks at the start of every follow-up. The runner shrugs and says it was fine.
Daniel turns the phone around and replays the 15-second clip from twelve weeks ago. The runner watches himself. He says, "Oh — I wasn't going that slow on the way down."
That sentence is the whole follow-up. It only happens if the prescription survived twelve weeks in a form the physio can reach in two taps.
One Last Thing
Physios don't lose follow-ups because they prescribe badly. They lose them because the prescription gets shorthanded at the end of a busy day, and the only person who could decode the shorthand is the same person who has thirty other charts to write before going home.
Adam Richmond, Ameeth Ruparelia, and the PTs in Gell's study are saying the same thing from three different angles, and the math hasn't moved. The schedule is unlikely to change tomorrow. But the tool you reach for at the door — when you're already saying the dose out loud — can.
Dr. Notes is on the App Store and Google Play. Try it for one week of follow-ups and see how visit three goes.
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