Client Consultation, Assessment, and Treatment Planning
Domain 1 examines whether you can screen a client safely, obtain informed consent, and turn assessment findings into a defensible treatment plan. The examiner looks for a logical sequence: intake, interview, observation, palpation, goal setting, plan, and documented consent.
Core rules and concepts
- Informed consent comes before touch. Explain draping, areas to be worked, expected sensations, and the client's right to stop at any time.
- A written intake must capture chief complaint, medical history, surgery, medications (especially anticoagulants, steroids, insulin), allergies (including nut oils and fragrances), pregnancy, skin conditions, and recent injury.
- Screen for red flags: fever, unexplained swelling, suspected DVT, uncontrolled hypertension, contagious skin infection, recent fracture, and intoxication. Refer rather than treat.
- Assessment uses observation, active and passive range of motion, palpation of tissue texture and temperature, and a pain scale. Record a baseline.
- The plan names goals, techniques, duration, frequency, areas avoided, and reassessment points. Keep goals functional and measurable.
Worked example
A 58-year-old client with type 2 diabetes reports numb, tingling feet and asks for deep calf work. Reasoning: peripheral neuropathy reduces protective sensation, so deep pressure can cause tissue injury the client cannot feel. Check skin integrity, use lighter pressure, avoid prolonged pressure over one spot, shorten the session, and refer for medical review if ulcers or sudden swelling are present. Document the finding and the modified plan.
Traps
Skipping medication questions, treating undiagnosed pain with aggressive pressure, assuming "no pain, no gain," and documenting consent only verbally after the session.