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SFMA: Documentation, Reassessment, and Outcome Tracking

SFMA · Work through your exam, one topic at a time.

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Documentation, Reassessment, and Outcome Tracking

Domain 8 - Documentation, Reassessment, and Outcome Tracking

The SFMA produces a defensible clinical record only if the scores, the reasoning and the retest are written down in a way another clinician could repeat. The exam tests whether you document the decision trail, not just the treatment, and whether your reassessment plan can actually show change.

What the record must contain

  • Date and the top-tier grid: each pattern, each side, one of FN, FP, DN or DP, plus where pain was felt.
  • Red flags screened and any referral made, with the reason and the outcome.
  • Breakouts performed and which one reproduced the top-tier limitation.
  • The movement diagnosis in one sentence, naming the limiting factor and the tissue or joint.
  • Intervention category, exercise, dose and the retest date.
  • Outcome measures at baseline and review.

Reassessment rhythm

  • Immediately after treatment, retest the pattern you treated; that is the only proof the intervention did anything.
  • At two weeks or three to four sessions, retest the whole top tier to catch new problems.
  • Expect pain to resolve before function, so the score often moves DP to DN to FN rather than straight to FN.

Outcome measures

Pain rating at rest and with the provoking movement, a patient-specific functional scale, a global rating of change, and the grid itself. Video the top-tier patterns from the same angle each time; it improves both reliability and your own pattern recognition.

Worked example

"14/03 - MSF DN, fingertips to mid-shin; seated forward bend equally limited; straight-leg raise 55/60. Limiting factor: posterior-chain extensibility. Plan: hamstring mobility and hip-hinge drill, retest 28/03." Review: "28/03 - MSF still DN but fingertips to floor; straight-leg raise 70/72; continue, add integration drill." That note shows the score, the reasoning, the dose and the change.

Traps that cost marks

  • Writing "patient improving" with no score or date.
  • No baseline, so improvement cannot be demonstrated.
  • Changing three interventions at once and calling the result a success.
  • Failing to document a referral, which is the note most likely to be scrutinised.