Physiotherapy Assessment: Step-by-Step Guide for Accurate Diagnosis

Last updated on July 5th, 2025 at 12:15 pm

A therapist’s success in treating a patient largely depends on how accurately he carries out a physiotherapy assessment. Are you the one having difficulty assessing your patient?  

In this post, we will discuss the step-by-step process of assessment. I have tried to simplify the process as much as possible so that anyone can understand. By the time you finish reading this post, if not excellent, at least you will be better than what you were before.  

Let’s get started.

Physiotherapy Assessment: The Key to Accurate Diagnosis

In the journey to successful treatment of a patient, an accurate diagnosis of the problem is half the battle won. If the case is accurately diagnosed and investigated, you will find that its treatment is not that complicated.  

On the other hand, treating a wrongly diagnosed case may not give you the desired result. To achieve accuracy, you have to master the art of assessment.

What Is a Physiotherapy Assessment? (Definition & Importance)

Assessment is a step-by-step process to interview and examine your patient and come to a provisional diagnosis. In a simple term, assessment is a strong foundation based on which you take the clinical decision and plan treatment.

If the foundation is accurate and strong enough, the outcome of the result will sometimes be even more than your expectations.

During my internship days, when we were first given independent charge of handling a case, I was literally nervous about taking an assessment. But with a little practice, I gained lots of confidence within a week.  

What’s Included in a Physiotherapy Assessment? [Step-by-Step]

Based on this provisional diagnosis you have to plan your treatment process. Please note that it’s just a provisional diagnosis; to make the confirmatory diagnosis, you have to correlate the assessment with all the investigative reports.

The investigative report can be anything, like an X-ray report, an MRI report, a CT-Scan report or any other report. You have to progress slowly from one part to the next proceeding part. With practice, you can master this art. And the best thing is that it is not at all difficult.    

But, you need to remember that the assessment process of neurological cases is quite different from the assessment process applied for orthopaedic/ pain cases.

Orthopaedic cases such as Cerebral palsy, quadriplegia, and hemiplegia need a different set of assessment procedures. But in this article, we will focus on assessing a case of an orthopaedic problem or a patient complaining of musculoskeletal kind of pain.  

What to Expect During Your First Physiotherapy Assessment

Remember as a kid when mum would take you to the doctor? The doctor would talk to your mum and with his handy torch would focus lights on your eyes and tongue. Actually, he is assessing you and trying to find out the reason.  

So, the assessment starts right from the beginning when a patient enters your chamber. You have to observe how the patient is being carried into the chamber, whether he is coming by himself or is carried by a family member. These are simple things that matter.  

How to Build Rapport During a Physiotherapy Assessment

Once the patient enters and settles in front of you, make them comfortable by giving a caring smile and asking about the problem. Believe me, that simple smile immediately connects a complete stranger to you and he begins accepting you.  

Connection with your patient is very important. It helps the patient to explain his problem in a much more comfortable and open way. He may reveal the things that otherwise would not have been shared.  

Studies also confirm that empathetic communication during assessments increases patient disclosure of critical symptoms. In the process of assessment, the smallest amount of information carries importance.

Once the patient is comfortable, he starts describing the problems and related incidents. Listen to them carefully and note down relevant information.  

So, let us progress on the steps of assessment. In this post, we will discuss only the skeleton of the perfect assessment process. Details on every point will follow in our next article. Till then try to master this.    

The 5-Step Physiotherapy Assessment Method (With Examples)

Please note that this step is only for assessing an orthopaedic/ pain case.

Step 1: Document the Chief Complaint (With Templates)

C/O-  Stands for patient’s chief complaint. Write whatever your patient complains. Avoid writing pre-diagnosed things here.  

Step 2: Taking a Detailed Patient History (Key Questions)

H/O- Stands for patient’s history related to the problem. History taking is very important. If taken in the right manner, the patient will reveal many secrets which not only help you diagnose the case, it will also help you sharpen your skill.

History taking involves the collection of the following important information:

• History of present illness.
• History of medication and treatment.
• Previous illness history.
• Jobs & professions.
• Family history

Step 3: Clinical Observation Techniques for Physiotherapists

O/O- stands for on observation. I just mentioned above how the patient is carried to your chamber, the way he walks and more below.

• How he is carried to the department.
• His/her body build (average/ with deformity).
• Whether he is cooperative, and responds to queries.

Step 4: Hands-On Physical Examination Protocols

O/E Stands for on examination. All the steps discussed above require social skills to connect with the patient. But, this examination step is where your actual professional skills come into play.

If you are weak in your theory part then you will be weak in your step 4 assessment.  

To master this part of the assessment, I suggest dusting off your books and revising all the crucial things. If not, then progress to the later part of this article.  

• You have to examine previous diagnostic reports (MRI/ CT-Scan/ X-Ray / NCV/ ECG  etc..)
• Look for actual pain points.
• Movements
• Etc.

Step 5: Formulating a Provisional Diagnosis (Case Study Tips)

Provisional diagnosis- this is where you analyse all the data collected from all the above processes. You need to cross-check the data and compare it with the medical report and their diagnosis.

Analyse..analyse…analyse… and try to come to your own conclusion about the actual cause of pain. When you come to a conclusion, it is what is your provisional diagnosis. However, this is not the final diagnosis.

As you progress with treatment, you will come across different things which may force you to alter your diagnosis. But, based on it your treatment planning starts.

Key Takeaways: Mastering Physiotherapy Assessments

It took several years of experience to master my diagnostic skills. But it is not at all difficult and anyone with a good knowledge base and commitment can master it, even more, faster than I.

Keep your assessment part near to perfect and your diagnosis will be exact. But if you are confused about the diagnosis, then treat your patient on the basis of the assessment.

Got questions about physiotherapy assessments? Leave a comment below!

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