Patient Record: Software or Word Template?
Your software has its own visit template. How to compare it with the elements of the individual physiotherapy care record, and when a Word template helps.
Records software has its own visit template. It looks professional and has drop-down lists with ICF and ICD codes. Is it the record the regulation talks about? Most likely yes, but it is worth checking for yourself. Below is a list of elements to compare with the template in your software.
Honest about us: we sell a patient record template (in the TARCZA package), so we have an interest in this topic. That is why we show how to compare the template in your software with the regulation without buying anything.
In brief
- The individual physiotherapy care record has elements set out in the medical records regulation: § 49(4) for a rehabilitation facility, and for a professional practice § 62, which refers to the same list.
- You compare the template in the software with the list of elements, not with the look of the record. A field may be named differently or sit on another tab.
- Your own visit templates are sometimes available only in paid plans, for example in ZenMed from the Start plan and in Medfile from the Plus plan.
- A vendor's declaration of compliance with the law concerns the program. The content of the entries remains your responsibility.
- A Word template does not replace the software. It is useful as a checklist, a printable version and a form for a failure.
What the regulation says about the record
The individual physiotherapy care record is described in the Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text, Journal of Laws 2026 item 1391). The elements of the record are set out in § 49(4), which concerns a rehabilitation facility. A physiotherapist providing services within a professional practice keeps the record under § 62: it is started when a service is provided for the first time (subsection 3), and subsection 4 states that it contains the data from § 49(4). The exception is a physiotherapist who practises solely inside a medical facility under a contract with a healthcare entity: that physiotherapist then makes entries in the records kept by that entity (§ 62(2)).
According to § 49(4), the record contains the information from subsection 3 (the patient's identification, the date and type of the procedure; a sequence number in the register of services is needed only if you keep a separate register, and for an electronic record keeping it is not required, § 49(2)) and also:
- the diagnosis of the disease, health problem or injury, or the diagnosis of pregnancy, information on past and coexisting diseases, and a description of the state of functioning,
- data on the physiotherapy management and its performance,
- a description of the health services provided,
- recommendations,
- information on certificates, opinions or statements issued,
- information on medical devices ordered by the physiotherapist,
- the date of the entry,
- the identification of the physiotherapist providing the service, in line with § 10(3) (first name and surname, professional title, right-to-practise number, signature).
A referral is also attached to the record, if applicable (§ 49(5)). This is a summary in our own words, not the full wording of the provision. When you set up the template, open the consolidated text and check each point. A broader discussion of the fields with their legal basis is in the article Physio patient record: template and fields.
How to check the template in your software step by step
Open a sample, empty visit record in the software and go through the table.
| Element | Where to look in the software | Present? |
|---|---|---|
| Patient identification data | Patient record, personal data | |
| Date and type of procedure | Visit entry, list of procedures | |
| Diagnosis, diseases, state of functioning | History, examination, ICD and ICF fields | |
| Physiotherapy management and its performance | Therapy plan, description of the course | |
| Description of services provided | Visit entry | |
| Recommendations for the patient | Recommendations field, exercise programs | |
| Certificates, opinions, statements | Attachments or a free-text field | |
| Medical devices ordered | Free-text field or list of orders | |
| Date of entry | Timestamp on the entry | |
| Identification of the physiotherapist (name, title, PWZ number, signature) | User account, signature on the entry | |
| Referral, if applicable | Attachments |
If an element is missing from the template, that is not yet an error. A field may be named differently or sit on another tab. If it simply is not there, ask the vendor about adding it or use a free-text field.
Your own templates are sometimes in paid plans
In some programs your own visit templates are available only in paid plans. In ZenMed visit templates come with the Start plan (PLN 49 gross a month), and in Medfile your own visit records appear from the Plus plan (PLN 119 gross a month). In the free plans you work on the vendor's template. As of 3 November 2026. More about the free plans: Free software for physiotherapists.
When a Word template helps
A record template in a Word file does not replace the software. It is useful in four situations:
- Checklist. You compare the fields of the template in the software with the fields of the Word template and fill in the gaps.
- Printable version. For example for home visits. Documentation for visits at the patient's home is covered in the article home physiotherapy: documentation.
- Software failure. When the system stops working during appointments, staff need a ready form. We described this in the article EDM failure.
- Changing software. The layout of fields from the template helps you move the template to a new program.
Just like the template in the software, compare a Word template with the list in § 49(4), and do not accept it as ready. The obligations connected with electronic records are covered in the article EDM: electronic medical records. If you keep records in software, do not rely on a Word template alone.
A patient record as a checklist for your software. The TARCZA package contains a patient record template, a therapy plan, a treatment log and a treatment consent template. Word files that you can compare with the templates in your software or print out. See the TARCZA package or compare all packages.
Frequently asked questions
Is the record template in the software compliant with the law?
Vendors usually declare compliance with the law. That is a declaration about the program. Responsibility for the content of the entries remains with you, so compare the elements of the template with the list in § 49(4) of the regulation.
What should I do if a field is missing from the software template?
Ask the vendor to add the field. In programs with your own templates (usually in paid plans) you can add it yourself. Otherwise use a free-text field, but record in it everything the provision requires.
Will the FizjoReady record template replace the template in my software?
No. It is a Word file that serves as a checklist and a printable version. You keep records day to day in the software.
Is the FizjoReady record template based on the regulation?
The template in TARCZA is a patient record in a Word file, and its instructions refer to the provisions. Provisions change, so when you set up a template, check the current wording of the regulation, not just the template.
Legal status as of: 3 November 2026
Legal basis: Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text Journal of Laws 2026 item 1391, announcement of 4 September 2026), § 10(2)-(3), § 49(1)-(5) and § 62(1)-(4), full wording checked in the consolidated text from api.sejm.gov.pl on 3 November 2026. Prices and plans of programs: vendors' websites as of 3 November 2026. We did not check: the other provisions of the regulation on entries and the form of records (§ 1, 4, 6), technical standards for EDM, the templates of specific programs after logging in, or whether the template in the TARCZA package covers every element of § 49(4) (compare it with the list in the same way as the template in your software).
Last reviewed: 3 November 2026
Related articles:
- Physio patient record: template and fields
- Is records software enough for a physiotherapy practice?
- Patient consent to a procedure in physiotherapy
- EDM: electronic medical records