Patient Assessment, Treatment Planning, and Documentation
This domain tests systematic assessment, goal setting, informed consent, and records that support continuity and legal defensibility. Expect questions on SOAP notes, objective measures, and re-assessment.
Core rules
- Assessment includes history, observation at rest and in motion, palpation, gait evaluation, neurological screening, and objective measures such as goniometry, circumference, and pain scores.
- Use baseline measures and re-measure. A treatment plan should be specific, measurable, achievable, relevant, and time-bound, with clear discharge criteria.
- Documentation follows a SOAP structure: subjective, objective, assessment, plan. Record date, time, consent, findings, interventions, parameters, response, and instructions.
- Communicate with the veterinarian and owner; obtain informed consent before treatment and explain alternatives and risks.
- Records should be contemporaneous, legible, and retained per practice policy; avoid speculation and label subjective findings as such.
Worked example
A horse has reduced thoracolumbar flexion and a short stride. Reasoning: document the baseline of pain on palpation, reduced range, and stride length. Set a goal to improve flexion by a measured amount and reduce the pain score within four weeks. Plan manual therapy plus controlled exercise, and schedule re-assessment. If neurological signs appear, stop and refer.
Traps
Recording only treated horse without parameters; setting vague goals; failing to document consent; and continuing treatment when the horse worsens instead of referring.