Assessment and handover

Published: 20/07/2020

These are my hints and tips to provide an effective framework for patient assessment and handover of their case to other Physiotherapists.

Consultations

Pre-consultation checklist

- Introduce yourself

- Confirm patient details (DOB, name and 1st line of address)

- Gain consent (and document in their patient notes)

Consultation plan considerations

Referral

- What information does the referral tell you?

- Consider the individual’s age for risk factors

- How might the symptoms related to potential pathologies

History

- What is the mechanism of injury?

- Occupation

- Previous injury in area?

- Aggravating and easing factors

- SIN - Severity, Irritability and Nature

- ICE – Ideas, Concerns, Expectations

Pre-objective assessment checklist

- Washed hands

- Explain the examination

- Warn the patient that the examination may provoke their familiar pain

- Ask the patient to tell you to stop if it becomes too painful or uncomfortable

Consider prior to physical examination

- Red flags

- SIN

- Family history

- Threads

Handover

Severity (VAS score)

Irritability --> How long the pain lasts or takes to settle after aggravation

Nature (e.g. Mechanical, Neural etc)

Stage (e.g. acute or chronic) / Stability (e.g. has the pain gotten better or worse over the past few months)

Aggravating factors

Easing factors

This checklist was taken from the YouTube video below.