Case History Taking in Physiotherapy
Establish patients’ case history
Type
Domain
Competency Area
Patient Care
Levels
Conduct holistic case history for routine cases independently.
Identify purpose of interviews and structure the interviews to achieve required outcomes
Gather information and develop client profiles
Determine if additional assessments of performance skills is required under guidance
Identify client strengths and potential problem areas
Establish priorities for interventions as part of the client interviews
Review medical and academic records of clients
Document interview processes and findings appropriately
Identify client and/or caregiver concerns
Build trust and rapport with clients and caregivers
Adhere to the code of conduct and other ethical or legislative guidelines in the handling of client information from the interview
Conduct holistic case history taking for routine and complex cases independently.
Integrate knowledge gathered by other professionals to form a holistic clinical impression of the clients
Collaborate with other professionals when validating interview findings for complex cases
Perform case history taking for complex cases requiring more in-depth knowledge or that have been escalated
Apply workplace violence procedures or workplace safety and health measures to protect against violent clients
Maintain professional code of conduct and/or confidentiality
Show sensitivity to cultural background and practices of clients, and adjust accordingly
Identify possible client conditions that may require modification to the interview structures
Provide guidance to junior therapists where necessary
Identify suitable adjuncts for interviews where necessary
Reflect on personal effectiveness in performing the interviews
Identify areas for improvement or client- related limitations that need to be addressed
Identify the most reliable source of information to establish the clinical history in clients
Identify gaps in information and seek to fill these gaps
Hypothesise potential problem areas