Physiotherapy assessment involves forming hypotheses, and thus a diagnosis, by way of questioning, observation and physical examination. It is a requirement of the Health and Care Professions Council (HCPC) as stated in the “Standards of Proficiency: Physiotherapists” All details and information recorded are highly confidential, so patient records must be maintained appropriately, and confidentiality of these never breached (HCPC 2013).
In the following report, I will be discussing the hypothetical assessment of a young boy ‘Miguel’, who suffered a supracondylar fracture. As he is under 16, he will be accompanied by a parent/guardian who may possibly contribute to the assessment process. Consent should also be given prior to assessment.
Subjective Assessment – History Taking
This subjective assessment forms a series of questions posed to the patient relating to their present condition/problem (Farr 2014a). Important factors that must be taken into consideration prior to treatment, such as patient preferences, contraindications, contributing factors, medication, family medical history, other medical conditions and previous medical investigations, are ascertained during this ‘history-taking’.
The subjective assessment consists of Presenting Condition (PC), History of Presenting Condition (HPC), Past Medical History (PMH), Social History (SH) and Drug History (DH) (Forrester-Gale 2014a).
During the PC, it is important that Miguel’s pain is documented. This