From First Question to Final Summary

A good physiotherapy assessment is not a collection of random questions and special tests. It should follow a clear structure from the moment the patient sits down to the moment they leave understanding what is happening and what comes next.

A useful assessment can be organised around six steps: understand why the patient is seeking help, take the history, perform a targeted examination, build a clinical picture, agree on goals and treatment, and finish with a clear summary.

Tools such as HSQ, SINSS, PSC, ICF, SMART goals and SOAP are not separate checklists. Each one has a specific role inside that process.

1. Start with the Health Seeking Question

Before asking about pain intensity, mechanism or previous treatment, find out why the patient is actually there.

The Health Seeking Question (HSQ) is the patient's request for help in their own words.

Useful questions include:

• “What made you decide to come now?”

• “What would you like physiotherapy to help you with?”

• “If treatment is successful, what will you be able to do again?”

This immediately gives direction to the rest of the assessment.

A patient may arrive with shoulder pain, but their real goal might be to play tennis again, return to work or sleep through the night.

That distinction matters because a successful treatment should eventually connect back to what the patient actually wants to achieve.

2. Use the history to decide how hard you can examine

The subjective assessment should explore the onset, mechanism, symptom behaviour, 24-hour pattern, previous episodes, medication, general health and the patient's own beliefs about the problem.

But the history should also tell you how much examination is appropriate today.

This is where SINSS becomes useful:

• Severity: How intense is the problem and how much does it limit activity?

• Irritability: How easily are symptoms provoked and how long do they take to settle?

• Nature: What type of problem might this be? Are there red or yellow flags?

• Stage: Is it acute, subacute or persistent?

• Stability: Is it improving, worsening or staying the same?

A highly irritable patient should not receive the same examination as someone with mild, stable symptoms.

If brushing their hair produces severe pain for several hours, repeatedly provoking the shoulder during testing is unlikely to add useful information.

SINSS therefore helps determine the dose of the assessment, not just the diagnosis.

3. Measure what matters to the patient

The Patient Specific Complaints (PSC) approach turns meaningful activities into measurable outcomes.

Ask the patient to identify three activities that matter to them and are currently difficult.

For example:

• Combing their hair

• Driving

• Making the bed

Each activity can then be scored from 0, no difficulty, to 10, impossible to perform.

These same activities can be re-tested later.
This gives you something more useful than simply asking, “Is your shoulder better?”
You can measure whether the patient is actually getting back to the activities that matter to them.

At the same time, screen for red flags and yellow flags. Serious pathology needs to be recognised early, while beliefs, fear, sleep, stress, work demands and coping strategies can strongly influence recovery.

4. Test your hypotheses, not everything

The physical examination should come from the history.
Every test should have a purpose.

A simple sequence might include observation, active movement, passive movement when relevant, load or resisted testing, neurological screening when indicated, selected special tests, palpation later in the examination, and finally a functional task related to the patient's complaint.

The key principle is simple:

Do not perform a test unless the result could change your reasoning or management.

Testing everything creates noise.

Instead, choose a small number of findings that reproduce the patient's problem and use them as re-test markers.

These might include:

• Range of movement

• Pain on resisted contraction

• A functional movement

• A timed task

• A patient-specific activity

These markers allow you to assess whether an intervention has created a meaningful immediate change.

5. Build the whole clinical picture

Once the subjective and objective assessment are complete, organise the findings.

The ICF model is useful because it prevents the assessment from becoming purely structural.

Think across several levels:

• Body functions and structures

• Activities

• Participation

• Personal factors

• Environmental factors

For example, a patient might have shoulder pain, reduced range of motion and weakness at the body level.

At the activity level, they struggle to comb their hair or drive.

At the participation level, they cannot play tennis with their club.

Their work demands, stress, beliefs, sleep and coping strategies may either help or slow recovery.

This broader picture is important because two patients with the same physical impairment can have completely different rehabilitation needs.

A good assessment should finish with three things:

1. A working hypothesis

2. The main factors influencing the problem

3. A prognosis

6. Turn the assessment into SMART goals

Goals should not be written for the patient. They should be agreed with the patient.

A vague goal such as:

“Improve shoulder function”

does not tell you much. A better short-term goal could be:

“Within three weeks, comb the hair without stopping, with difficulty reduced to 3/10 or less.”

A long-term goal might be:

“Within eight weeks, complete a 60-minute tennis session with pain no higher than 3/10 and no increase the following morning.”

The goal is now specific, measurable, achievable, relevant and time-bound.
Treatment should then follow directly from those goals.

The plan should include the intervention, exercise dose, home programme, frequency of treatment, progression criteria, re-evaluation date and any findings that would trigger referral.

7. SOAP keeps the whole process organised

SOAP provides a simple way to document everything:

S – Subjective: What the patient tells you
O – Objective: What you observe and measure
A – Assessment: What you conclude and why
P – Plan: What you and the patient will do next

A common mistake is mixing these sections.
“I cannot play tennis” belongs in Subjective.
“Pain reproduced at 120 degrees of elevation” belongs in Objective.
“Findings suggest a load-sensitive shoulder presentation” belongs in Assessment.
“Three strengthening sessions per week” belongs in Plan.
Keeping these categories clear also makes communication with other clinicians much easier.

The step that is often missed: the final summary

A technically excellent assessment can still fail if the patient leaves confused. The final two minutes matter.

Summarise three things in simple language:

What is going on:
“Your shoulder is sensitive to load after a large increase in tennis.”

What it means:
“This type of problem usually responds well to gradually rebuilding strength and tolerance.”

What happens next:
“We will reduce the aggravating load slightly, start with these exercises and progressively build back towards tennis.”

Avoid unnecessary jargon.

Instead of saying “high irritability,” say “your shoulder is very sensitive right now.”

Instead of “load management,” say “finding the right amount, not too much and not too little.”

Then use teach-back:

“Just to check I explained it clearly, can you tell me what you think is happening and what you are going to do at home?”

This is not testing the patient.

It is testing your explanation.

The whole assessment in one line

A strong physiotherapy assessment should move logically from:

What does the patient want? → What is the problem? → How sensitive is it? → What can I measure? → What is my working hypothesis? → What matters functionally? → What are our goals? → What is the plan? → Does the patient understand it?

That is the difference between simply collecting findings and performing a structured clinical assessment.