Assessment and Treatment Planning
Domain overview
This domain tests whether you can gather information systematically, identify contraindications, set measurable goals, and document a plan another practitioner could follow. Questions often ask what to do next, what to document, or when to refer.
Core rules
- Use a structured interview and assessment: chief complaint, history, medications, health conditions, occupation, lifestyle, and client goals.
- Separate subjective data (what the client reports) from objective data (observation, palpation, range of motion, special tests).
- Screen for red flags before treatment: unexplained weight loss, fever, night pain, neurological deficits, chest pain, sudden severe headache, suspected fracture, or infection.
- Write goals that are specific, measurable, and time-bound; reassess and revise them.
- Document in SOAP or another consistent format: Subjective, Objective, Assessment, Plan.
- Refer when findings suggest a condition requiring medical diagnosis or treatment.
Worked example
A client reports three days of low back pain after lifting, with pain radiating below the knee and new numbness in the foot. Reasoning: radicular symptoms and sensory change are red flags for nerve involvement. Do not proceed with deep lumbar work; document the findings, advise medical evaluation, and offer only comfort measures within scope if allowed.
Traps that cost marks
- Skipping the interview because the client just wants a massage.
- Treating a new symptom as a muscle strain without screening.
- Writing vague goals such as relax the back.
- Failing to record referrals and client responses.