Client Assessment/Reassessment
The assessment sequence
Assessment moves from general to specific: intake and health history, observation (posture, gait, symmetry, breathing, skin), palpation (temperature, tone, texture, tenderness, edema), range of motion, and then special or orthopedic tests. Intake should capture medications, surgeries, injuries, current medical care, chief complaint, goals, and lifestyle.
Range of motion and strength
Active ROM is the client's own movement; passive ROM is you moving the joint with the client relaxed; resistive ROM applies resistance to test strength and pain. End feels are normal (bony, capsular, soft tissue) or abnormal (empty, springy, spasm). Manual muscle testing grades strength typically from 0 (no contraction) to 5 (normal against full resistance).
Documentation
SOAP notes organize the record: Subjective (client's report), Objective (measurements, palpation, ROM), Assessment (your clinical impression within scope), and Plan (techniques, goals, next session, referral). Reassessment after treatment confirms change and informs the next plan.
Traps
The exam loves confusing active with passive ROM and asking what belongs in each SOAP section. Objective findings must be observable or measurable - the client's description of pain belongs under Subjective even if you wrote it down during observation.
Rule of thumb
Compare bilaterally. Findings matter most as differences between sides and against the client's baseline - always reassess the same measure you used at intake.