Interactive guided tour
See a recorded initial evaluation become a professional report.
Follow one fictional physical therapy patient from the schedule through a clinical conversation, a structured evaluation, clinician corrections, and the patient record. The same workspace also models chiropractic and mixed PT/chiropractic practice workflows.
Fictional initial evaluation
Jordan Miles · right ankle injury
Step 1 of 4
Open the evaluation from the schedule
Visit type, patient, provider, and available records carry into the evaluation workspace.
Licensed physical therapists can be shown as PT or PT, DPT. This evaluation is assigned to a PT, DPT; PTA and tech-assisted visits remain appropriate follow-up options but cannot become initial evaluations. Mixed clinics also keep DC schedules and chiropractic initial, daily, re-exam, and discharge workflows distinct.
Talk with the patient—not to the report
Most of the source is ordinary conversation and examination talk. A short plan dictation captures only the details the clinician wants stated precisely.
Clinician Before we look at it, walk me through what happened to the right ankle.
Jordan About three weeks ago I stepped off a curb and my right foot rolled inward. The outside swelled up and bruised pretty quickly.
Clinician Did you have it checked?
Jordan Yes. Urgent care took X-rays and said there was no fracture. They gave me a lace-up brace. I mostly wear it when I leave the house.
Clinician What does it feel like today?
Jordan Mostly a dull ache on the outside—about a two out of ten right now and maybe a one at best. On stairs, uneven ground, or if I stand too long, it can get sharp and go up to a six.
Clinician What settles it down?
Jordan Ice, putting it up, the brace, and getting off my feet. It still looks a little puffy by evening.
Clinician How is that changing your normal day?
Jordan I teach, so I am usually standing most of the day. Now I start limping by lunch. I use the stair rail, I will not carry laundry downstairs, and I stopped hiking. Around the house I am okay, but I want to teach a full day without limping, take stairs without the rail, and get back to my two-mile trail.
Clinician Any numbness or tingling? Calf pain, trouble breathing, locking, or another fall?
Jordan No, none of those. I do have high blood pressure, but it is controlled. I have never had ankle surgery or a prior ankle fracture.
Clinician All right—walk to the wall and back for me at your normal pace.
Jordan I can feel myself getting off the right side quicker.
Clinician I see that too: your right stance phase is a little shorter, and there is still mild swelling along the outside. Let us check motion next. Right ankle dorsiflexion is seven degrees; the left is fifteen. Plantarflexion is forty-two on the right and forty-five on the left.
Clinician Now push the outside of your right foot into my hand. Does that reproduce the pain?
Jordan Yes, right along the outside.
Clinician Right eversion is four minus out of five with that familiar lateral pain; the left is five out of five. Light-touch sensation feels the same on both sides?
Jordan Yes.
Clinician Sensation is intact and symmetric. You are tender over the ATFL. The anterior drawer has mild laxity but a firm endpoint, and that is your familiar pain. Talar tilt is negative.
Clinician Let us try standing on one leg. I have five seconds on the right and thirty on the left. Now step down from this four-inch step.
Jordan I need the rail, and that brings the outside pain back.
Clinician I saw that. Your Lower Extremity Functional Scale score is forty-eight out of eighty. Putting everything together, this fits a healing right lateral ankle sprain. The main things holding you back are limited dorsiflexion, painful eversion weakness, reduced single-leg balance, the shorter right stance time, and difficulty with prolonged standing, stairs, and uneven ground.
Jordan Does it look like I should be able to get back to normal?
Clinician Your rehab potential looks good. Skilled PT will let us progress loading, balance, gait, and stairs safely instead of guessing. In two weeks, I want stair pain at three out of ten or less, dorsiflexion at least twelve degrees, and right single-leg balance at least twenty seconds.
Jordan And getting all the way back to teaching and hiking?
Clinician Our six-week targets are fifteen degrees of dorsiflexion, thirty seconds of balance, a full teaching day without limping, stairs without the rail, and your two-mile trail without increased pain or swelling.
Clinician For home, start with ankle pumps, banded eversion, and supported single-leg balance. Hold off on running, jumping, and uneven-trail hiking until your strength, balance, and symptoms meet those goals. We will keep rechecking pain, swelling, motion, eversion strength, balance, and stairs.
Jordan That sounds manageable.
Clinician Quick plan note: physical therapy twice weekly for six weeks, including ankle mobility, progressive strengthening, balance and proprioception, gait and stair training, and manual therapy as indicated.
The clinician can stay in the patient conversation, say measurements as they are taken, and dictate only when useful. LocalChart organizes the scattered history, findings, goals, and plan into the evaluation while preserving the source for comparison.
Turn the transcript into the LocalChart initial evaluation
The production workflow organizes the same facts into its full PT evaluation structure. The clinician still confirms the source before approval.
Patient information
Name: Jordan MilesDOB: 02/03/1987Date of evaluation: 07/21/2026Referring provider: Morgan Lee, PA-CDiagnosis: Right lateral ankle sprainPrecautions: No running, jumping, or uneven-trail hiking until strength, balance, and symptoms meet the stated goals.
Subjective
Jordan reports a right lateral ankle injury three weeks ago after stepping off a curb. Urgent-care X-rays were negative for fracture. Pain is a dull lateral ache rated 2/10 currently, 1/10 at best, and up to 6/10 with stairs, uneven ground, or prolonged standing. Ice, elevation, the brace, and rest help. Mild evening swelling persists. He denies numbness, tingling, calf pain, shortness of breath, locking, and another fall. History includes controlled hypertension with no prior ankle surgery or fracture.
Pain and functional context
Jordan begins limping by lunch during his teaching day, uses the stair rail, avoids carrying laundry downstairs, and has stopped hiking. He can walk around the house. Patient-stated goals are a full teaching day without limping, stairs without the rail, and return to a two-mile trail.
Observation, posture, and gait
Mild right lateral ankle swelling was observed with a mildly shortened right stance phase.
Range of motion and strength
Right dorsiflexion measured 7° versus 15° on the left. Plantarflexion measured 42° on the right and 45° on the left. Right eversion tested 4-/5 with familiar lateral pain; the left tested 5/5.
Tests, neurological screen, and functional performance
Light-touch sensation was intact and symmetric. ATFL palpation was tender. Anterior drawer showed mild laxity with a firm endpoint and familiar pain; talar tilt was negative. Right single-leg stance was 5 seconds versus 30 seconds on the left. A four-inch step-down required the rail and reproduced lateral pain.
Outcome measures
Lower Extremity Functional Scale: 48/80.
Assessment
The provider’s clinical impression is a healing right lateral ankle sprain with dorsiflexion restriction, eversion weakness, impaired balance, and limited tolerance for prolonged standing, stairs, and uneven terrain. Rehab potential is good. The provider states that skilled physical therapy is needed to progress loading, balance, gait, and stair function safely.
Problem list
Limited right dorsiflexion; painful eversion weakness; impaired right single-leg balance; altered gait tolerance; difficulty with stairs and uneven-ground walking.
Goals
Patient-stated: Full teaching day without limping; stairs without the rail; return to a two-mile trail. Two weeks: stair pain no higher than 3/10, dorsiflexion at least 12°, and right single-leg stance at least 20 seconds. Six weeks: dorsiflexion 15°, right single-leg stance 30 seconds, full teaching day without limping, stairs without the rail, and a two-mile trail without increased pain or swelling.
Plan of care
Physical therapy twice weekly for six weeks. Planned interventions include ankle mobility, progressive ankle and lower-extremity strengthening, balance and proprioceptive training, gait and stair training, and manual therapy as indicated. The home program includes ankle pumps, resisted eversion with a band, and supported single-leg balance. Reassess pain, swelling, dorsiflexion, eversion strength, balance, and stair tolerance.
Documentation notes
Missing information: None identified from the supplied patient context and recorded evaluation.
The report is not a generic SOAP summary. It follows LocalChart’s actual PT initial-evaluation structure, and every clinical result shown above is present in the patient context or recorded conversation.
Keep the evaluation with the patient
Approved documentation, source material, draft history, and imported records remain connected without being confused with one another.
At the next visit, the provider can find the approved evaluation and its relevant history without treating an AI draft or raw transcript as a signed clinical record.
Automatic patient memory · grounded in approved reports
Open the next visit already caught up.
LocalChart turns the clinician-approved chart into usable continuity. It organizes the episode, compares change over time, keeps unfinished goals and the latest plan visible, and supplies approved context for the next report—without making the clinician reread every prior note.
Indexes the clinical story
Measurements, functional changes, goals, active issues, and plan decisions are linked to the patient’s episode from each approved report.
Compares what changed
Baseline and recent findings are organized into a readable trajectory so improvement, plateaus, and remaining limitations are easier to spot.
Builds a clinical briefing
The latest plan, unfinished goals, relevant history, and items due for reassessment are brought together before the clinician continues care.
Reuses approved context
The next draft can start with the approved episode history instead of forcing the clinician to reconstruct it or repeatedly copy old notes.
Baseline and plan of care
Three weeks after inversion injury. Limited standing, stairs, laundry carrying, and hiking. Plan established for mobility, strength, balance, and return to function.
Swelling begins to settle
Brace still used outside the home. Tolerated ankle mobility, resisted strengthening, and supported balance work. Limp now begins later in the teaching day.
Stair control is improving
Began four-inch step-down training and progressed uneven-surface balance. Patient carries light laundry upstairs but remains cautious descending.
Full workday restored
No longer limping during a normal teaching day. Reciprocal stairs are improving; hiking goal has not yet been tested. Plan continues with dynamic balance and uneven terrain.
Ready for longer trail progression
Uses stairs without the rail and completed a one-mile uneven walk without increased swelling. Two-mile hiking goal remains active before discharge planning.
Start the visit with the current story
The provider does not have to open five separate reports to find the last plan, precautions, baseline measures, or incomplete goals.
Progress reports begin with the trajectory
Changes in pain, motion, balance, function, and goal status are already organized for review instead of manually rebuilt from old documentation.
Handoffs preserve the plan
An authorized clinician can see what mattered, what changed, and what should happen next without relying on memory or copy-and-paste.
The efficiency gain: LocalChart does the repetitive retrieval and organization. The clinician keeps the clinical judgment—reviewing the source, correcting the draft, choosing the plan, and approving what becomes part of the chart.
What becomes patient memory
Clinician-approved reports, measurements, goals, active issues, and imported records that staff have accepted into the chart.
What stays separate
Raw recordings, transcripts, and unfinished drafts remain labeled source material rather than silently becoming approved clinical facts.
Who controls the chart
The clinic controls staff access, retention, backups, recovery, and exports on its LocalChart host.