Cerebral Palsy/Spasticity Management Note

Date: [date]

Patient: [name and MRN]

Provider: [name, credentials]

Visit Type: [new / established], [in-person / telehealth]

Historian: [patient / parent/guardian / caregiver] (Note if interpreter or AAC used.)

Decision-Maker: [parent/guardian name and relationship] (Include only if applicable.)

Reason for Visit: [chief concern or primary purpose]

CP Baseline Profile

(This section captures stable longitudinal facts. Review and update each visit; do not blindly copy forward.)

Diagnosis: [CP subtype (spastic/dyskinetic/ataxic/mixed), distribution (hemi-/di-/quadriplegia), etiology if known, key neuroimaging summary]

Classifications: [GMFCS, MACS, CFCS, EDACS levels] (If not assessed, state "not yet classified.")

Baseline Function: [mobility method, transfer status, upper limb function, communication/AAC, therapy setting]

Equipment/Orthoses: [current orthoses with wear schedule, wheelchair/seating system, stander, gait trainer, other DME]

Relevant Surgical History: [SDR, ITB pump, orthopedic procedures affecting tone/gait]

Subjective

Patient/Family Priorities: [1–3 top concerns in patient/family words, focusing on function, comfort, care burden, or participation]

Functional Goals: (Document SMART, function-first goals linked to impairments. For each goal, include goal statement, baseline status, target outcome, timeframe, and linked impairment. If goals cannot be established today, document why and plan to define at next visit.)

• Goal #1: [goal statement tied to domain] — [baseline status] → [target outcome] within [timeframe]; linked to [impairment]
• Goal #2: [as above] (Add additional goals only if meaningful and feasible.)

Interval History: [changes since last visit: hospitalizations, surgeries, growth spurts, pain, skin issues, therapy interruptions, equipment changes]

Tone Symptoms: [spasm patterns, triggers, interference with gait/transfers/hygiene/seating/sleep; comfort and pain with location and severity]

Therapy/Orthosis Status: [PT/OT/SLP frequency and response; orthosis wear tolerance/fit issues; home program adherence]

Prior Intervention Response: [response to oral meds (benefit, adverse effects, adherence); prior injections (targets, response vs goals, duration, adverse events)] (Include only if applicable.)

Objective

Weight: [weight in kg] (Required for dosing. If unavailable, state "weight needed prior to dosing.")

General: [distress level, alertness, participation in exam]

Tone Exam: [tone type (spasticity / dystonia / mixed) and distribution by region/muscles; MAS/MTS with R1/R2 if performed; for dystonia, note fluctuation/overflow/triggerable postures, focal vs generalized] (Do not auto-fill scales not performed. If omitted and potentially relevant, state "not assessed today.")

ROM: [key joints relevant to gait/positioning: hip abduction, hip flexion contracture, popliteal angle, ankle DF with knee flexed/extended; upper limb if targeted; note fixed vs flexible deformity and pain with ROM]

Strength/Motor Control: [functional descriptors; selective motor control if relevant]

Functional Observations: [transfers; sitting/standing balance; gait characteristics (barefoot vs braced, device use, endurance, toe walking/crouch/scissoring, symmetry); upper limb reach/grasp/release and bimanual function] (Tailor observations to GMFCS level and stated goals.)

Equipment Check: [orthosis fit, skin findings, wear issues; wheelchair seating posture and pressure areas] (Include only if assessed.)

Data Reviewed: [study type and date: key finding → impact on plan] (List imaging, gait lab reports, therapy evaluations, or outside records reviewed.)

Assessment

[Brief clinical synthesis: active problems today; how tone impacts function and care; likely mechanism (dynamic spasticity vs dystonia vs fixed contracture vs weakness); what changed since last visit] (Do not recapitulate full history/exam. Label hypotheses as "suspect" or "likely" if uncertain, with alternatives when relevant.)

Problem List:

1. [Problem 1]
2. [Problem 2]
3. [Problem 3]

(List in descending clinical priority. Include only active problems.)

Plan

(Organize by problem area. For each, tie interventions to functional goals and objective anchors.)

Tone Management: [tone type and distribution; treatability (dynamic vs fixed); interventions including stretching/positioning, oral meds (indication, dose, titration, side effect counseling), and whether chemodenervation is indicated; target muscles and goal linkage if planning injections]

Mobility/Gait: [gait pattern contributors; device/training recommendations and rationale]

Orthoses/Positioning: [orthosis type; goal it supports; wear schedule; skin precautions; orthotist follow-up]

Therapy Coordination: [frequency; focus areas aligned to goals; post-intervention therapy plan; coordination tasks]

Equipment/DME: [item ordered; functional limitations requiring it; why alternatives insufficient; home/school environment factors] (Do not infer home accessibility or caregiver capacity.)

Orthopedic Surveillance: [hip surveillance status (ROM, migration percentage if known); scoliosis concerns; referral thresholds] (Include only if applicable.)

Care Coordination: [communications with therapy, orthotics, school, or other providers; shared planning responsibilities]

Follow-up: [reassessment timing aligned to interventions; criteria for success; earlier return precautions]

Procedure Documentation

(Include this section only when chemodenervation is performed today.)

Indication: [tied to documented goals]

Consent: [who consented, laterality confirmed, time-out completed]

Product: [name, lot/expiration if tracked, total units drawn, total units injected, total units discarded]

Technique: [guidance method; muscles injected by side with units per muscle; needle type; patient positioning]

Analgesia/Sedation: [method used and tolerance]

Complications: [complications or "none"]

Post-Procedure Instructions: [activity restrictions, therapy timing, warning symptoms for systemic spread including swallowing/breathing changes, when to seek urgent care]

Orders

• [Medications: name, dose, route, indication]
• [Therapy referrals: discipline, frequency, focus, indication]
• [Imaging/Labs: test, indication]
• [Orthotics: type, goals, indication]
• [DME: item, indication, justification]
• [Procedures scheduled: type, targets, indication]

(Include only orders placed. For safety-critical fields such as weight for dosing, baseline tone before injection, and consent, use explicit placeholders. For non-critical fields, omit rather than entering "N/A." Do not infer functional classification levels, swallowing safety, dystonia presence, equipment needs, or caregiver capacity.)