Case History Taking in Physiotherapy

Establish patients’ case history



Competency Area

Patient Care


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