Client Intake, Assessment, and Documentation: Assessment

Gathering assessment data will take place in two sections, with the first being subjective data that the client provides from his/or her own point of view, and the second being information that is collected from objective assessment techniques. After these are combined, the three other areas - plan, implementation, and evaluation - can be performed.

Subjective data is information that the client offers to the therapist regarding pain and problems, and it is subjective as the client has a personal bias towards the information. Information that is on the written disclosure form, information that is on the intake form, and information that the therapist receives when questioning the client is all subjective information.

Objective data, on the other hand, comes from the therapist and is made up of the therapist's assessment of the client. Any objective information provided must be precise and measurable. For example, the therapist could say that the client's right shoulder is higher than the other and that is it inflamed near the top. Measurements of a goniometer can be also be listed as well as the client's range of motion.

A record assessment protocol is sometimes used (also called a RAP), and it makes sure that the information is complete and correct. Basically, this is a checklist of criteria that will keep errors and omissions from being made. RAPs will list: the client's skin color, the skin temperature, the skin condition, the swollen lymph nodes, the anomalies, the superficial fascia, the localized or generalized tenderness, the muscle tension, tone, spasms, and atrophy, the vertical structural landmarks, breathing, gait, and range of motion.