16/10/2025
An excellent post from Veterinary Compendium - Thanks
Since yesterday's Community Gathering was all about patient intake, assessments, and client reporting, it would be timely to share this blog and Debranne Pattillo's photo:
https://vetcompendium.org/courses/practitioners-documentation-tools-best-of/
𝐓𝐡𝐞 𝐖𝐡𝐨𝐥𝐞-𝐁𝐨𝐝𝐲 𝐀𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭
by Kevin Haussler, DVM, DC, PhD
and Debranne Pattillo, MEEBW, ASTR, MSc.(h.c.)
𝑊𝑒 𝑏𝑒𝑙𝑖𝑒𝑣𝑒 𝑡ℎ𝑎𝑡 𝑝𝑟𝑎𝑐𝑡𝑖𝑡𝑖𝑜𝑛𝑒𝑟𝑠 𝑤ℎ𝑜 ℎ𝑎𝑣𝑒 𝑏𝑒𝑒𝑛 𝑡𝑟𝑎𝑖𝑛𝑒𝑑 𝑖𝑛 𝑎 𝑑𝑖𝑣𝑒𝑟𝑠𝑒 𝑎𝑟𝑟𝑎𝑦 𝑜𝑓 𝑎𝑠𝑠𝑒𝑠𝑠𝑚𝑒𝑛𝑡 𝑡𝑒𝑐ℎ𝑛𝑖𝑞𝑢𝑒𝑠 𝑐𝑎𝑛 𝑎𝑙𝑙 𝑝𝑟𝑜𝑣𝑖𝑑𝑒 𝑢𝑛𝑖𝑞𝑢𝑒 𝑐𝑙𝑖𝑛𝑖𝑐𝑎𝑙 𝑖𝑛𝑠𝑖𝑔ℎ𝑡𝑠, 𝑏𝑢𝑡 𝑡ℎ𝑜𝑠𝑒 𝑎𝑠𝑠𝑒𝑠𝑠𝑚𝑒𝑛𝑡𝑠 𝑚𝑢𝑠𝑡 𝑏𝑒 𝑏𝑎𝑠𝑒𝑑 𝑜𝑛 𝑎 𝑤ℎ𝑜𝑙𝑒-𝑏𝑜𝑑𝑦 𝑎𝑝𝑝𝑟𝑜𝑎𝑐ℎ 𝑎𝑛𝑑 𝑏𝑒 𝑎𝑠 𝑑𝑒𝑡𝑎𝑖𝑙𝑒𝑑 𝑎𝑠 𝑝𝑜𝑠𝑠𝑖𝑏𝑙𝑒.
Veterinarians and human-trained chiropractors, osteopaths, and physical therapists are taught, during their extensive training programs, thorough physical examination protocols that guide their treatment plans. These licensed practitioners know how critical it is to take the time and have the necessary resources to conduct a comprehensive evaluation – not only for that initial client visit, but also to assess the patient’s longer-term response to care.
If we neglect to take the time to establish a 𝐰𝐞𝐥𝐥-𝐝𝐞𝐟𝐢𝐧𝐞𝐝 𝐛𝐚𝐬𝐞𝐥𝐢𝐧𝐞 𝐨𝐟 𝐜𝐥𝐢𝐧𝐢𝐜𝐚𝐥 𝐩𝐚𝐫𝐚𝐦𝐞𝐭𝐞𝐫𝐬 (relative to the individual practitioner’s scope of practice), then how can we build a sensible treatment plan? Or provide any realistic updates to the client of significant improvements provided by our clinical services, or justify our fees or continued treatment?
Another key reason why physical assessment is of critical importance is that treating an animal, without first taking a complete patient history and performing a thorough assessment, can be harmful to both patient, owner, and practitioner. Dr. Haussler’s January 2024 blog post, Recognizing Red Flags, discussed the importance of screening patients for infectious, contagious and zoonotic diseases, and avoiding contact or doing immediate referral of potentially affected animals.
Another example: Applying chiropractic treatment to a horse with ataxia due to spinal cord compression or a primary limb lameness due to a hoof abscess would be issues of great concern if treatment was applied without any consideration of the cause of the clinical complaint or diagnosis.
𝐓𝐡𝐞 𝐚𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭 𝐭𝐫𝐚𝐢𝐧𝐢𝐧𝐠 𝐠𝐚𝐩
For practitioners who have pursued training or certification to work with animals – chiropractors, osteopaths, physical therapists, massage therapists, bodyworkers, acupressure practitioners – the same standards for training in physical examination procedures is expected, which implies that graduates of these programs are taught to routinely perform a thorough assessment of their patient before proposing a treatment plan or applying any therapy.
Unfortunately, some training or certification programs for animals do not provide any or only limited didactic or practical course content on assessment techniques. Despite this fact, these training programs are often considered to be reputable because their curriculum provides extensive training in treatment techniques (i.e., how to apply the techniques), requirements for externships, case studies, and hands-on validation of the student’s work. This implies that the graduates of these programs would theoretically know how to do the treatment work but would not know if the patient standing before them has any specific clinical indications that could inform their treatment plan or whether that patient might be harmed by having specific manual therapy techniques performed.
And what about the training or certification programs that have lower standards or fewer requirements for the length of study, quality of instruction, or a lack of oversight or hands-on training? Have graduates of these programs learned the value of taking a detailed history and conducting a whole-body evaluation? Or have they recognized some of the shortcomings of their initial training and then pursued additional training to develop their assessment skills?
For animal bodyworkers, learning and then applying a whole-body assessment is essential for recognizing discomfort, improvements, and to know when referral for veterinarian intervention is required (as outlined in the Recognizing Red Flags blog post). Graduates of various programs may be unaware of the need for comprehensive assessment guidelines since they simply do not know what they do not know.
𝐖𝐡𝐲 𝐭𝐡𝐞 𝐥𝐚𝐜𝐤 𝐨𝐟 𝐚𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭?
There are several possible explanations why assessment techniques might not be taught or are only a minor component of a certification or training program, or are not completed on every patient at every visit:
𝑮𝒆𝒏𝒆𝒓𝒂𝒍 𝒂𝒑𝒑𝒍𝒊𝒄𝒂𝒕𝒊𝒐𝒏 – A belief that every living being has issues somewhere in their body and finding the exact location or affected tissue is not that important – just applying a treatment somewhere will help the patient.
𝑳𝒂𝒄𝒌 𝒐𝒇 𝒕𝒊𝒎𝒆 – As some of these training programs are offered over a weekend or limited to less than 100 hours, there may not be time enough to cover all the needed topics. Therefore, the focus is on the technique or training method itself and less on the evaluation procedures.
𝑳𝒂𝒄𝒌 𝒐𝒇 𝒆𝒙𝒑𝒆𝒓𝒕𝒊𝒔𝒆 – The instructor lacks the awareness or may not have qualifications as they were not taught how to do detailed whole-body assessment techniques during their own training.
𝑫𝒊𝒇𝒇𝒊𝒄𝒖𝒍𝒕𝒊𝒆𝒔 𝒊𝒏 𝒕𝒓𝒂𝒏𝒔𝒍𝒂𝒕𝒊𝒐𝒏 𝒇𝒓𝒐𝒎 𝒉𝒖𝒎𝒂𝒏 – Many of the techniques that we use with animals have been transposed from use in humans. However, human-based techniques may not wholly translate to the quadrupedal, nonverbal, haired, animal patient. Similarly, human-trained instructors may find it difficult to effectively shift their teaching methods from the human to animal patient.
𝑪𝒍𝒊𝒆𝒏𝒕 𝒓𝒆𝒔𝒊𝒔𝒕𝒂𝒏𝒄𝒆 – Bodyworkers report that they sometimes encounter resistance from clients because of the additional time and associated cost required to collect a complete medical history and conduct a comprehensive physical examination – sometimes the client just wants a “quick fix”. It can be helpful to explain to clients why the information needs to be collected and to demonstrate a full-body assessment. If they still resist, then there is a possibility that they may not continue to be a client.
𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐩𝐫𝐚𝐜𝐭𝐢𝐜𝐞 𝐚𝐧𝐝 𝐚𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭 𝐭𝐞𝐜𝐡𝐧𝐢𝐪𝐮𝐞𝐬
It is important to note that assessment techniques vary according to an individual’s scope of practice and the different modalities or manual therapies that are applied. Practitioners vary in their training and individual area of interest or focus and therefore may not perform the same physical evaluation procedures.
Certain clinical or diagnostic techniques are and should be reserved for veterinarians or other licensed practitioners trained in those specific methods. For example, a massage therapist with training focused primarily on myofascial issues is not qualified to do a cranial drawer test on a dog’s stifle and should not be discussing how to manage a ruptured cranial cruciate ligament. It is important to have a clear understanding of our scope of practice and specific training, and what assessment techniques we should and should not be performing.
Practitioners also need to be aware that in navigating the complexities of veterinary regulatory language, they face potential pitfalls. State veterinary practice acts wield considerable authority, with terms that if used by non-veterinarians could easily be construed as infringing on the practice of veterinary medicine. While some practice acts provide clarity on the roles of practitioners, many do not. Therefore, it is crucial for practitioners to use terms that align with their scope of practice, to avoid legal repercussions.
For instance, in Texas, animal bodyworkers received cease and desist letters for using terms such as “evaluation”. The veterinary medical board cited codes from the definition of veterinary practice (§ 801.002.):
(5) “𝑃𝑟𝑎𝑐𝑡𝑖𝑐𝑒 𝑜𝑓 𝑣𝑒𝑡𝑒𝑟𝑖𝑛𝑎𝑟𝑦 𝑚𝑒𝑑𝑖𝑐𝑖𝑛𝑒” 𝑚𝑒𝑎𝑛𝑠:
(𝐴) 𝑡ℎ𝑒 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑖𝑠, 𝑡𝑟𝑒𝑎𝑡𝑚𝑒𝑛𝑡, 𝑐𝑜𝑟𝑟𝑒𝑐𝑡𝑖𝑜𝑛, 𝑐ℎ𝑎𝑛𝑔𝑒, 𝑚𝑎𝑛𝑖𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛, 𝑟𝑒𝑙𝑖𝑒𝑓, 𝑜𝑟 𝑝𝑟𝑒𝑣𝑒𝑛𝑡𝑖𝑜𝑛 𝑜𝑓 𝑎𝑛𝑖𝑚𝑎𝑙 𝑑𝑖𝑠𝑒𝑎𝑠𝑒, 𝑑𝑒𝑓𝑜𝑟𝑚𝑖𝑡𝑦, 𝑑𝑒𝑓𝑒𝑐𝑡, 𝑖𝑛𝑗𝑢𝑟𝑦, 𝑜𝑟 𝑜𝑡ℎ𝑒𝑟 𝑝ℎ𝑦𝑠𝑖𝑐𝑎𝑙 𝑐𝑜𝑛𝑑𝑖𝑡𝑖𝑜𝑛, 𝑖𝑛𝑐𝑙𝑢𝑑𝑖𝑛𝑔 𝑡ℎ𝑒 𝑝𝑟𝑒𝑠𝑐𝑟𝑖𝑝𝑡𝑖𝑜𝑛 𝑜𝑟 𝑎𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑎 𝑑𝑟𝑢𝑔, 𝑏𝑖𝑜𝑙𝑜𝑔𝑖𝑐, 𝑎𝑛𝑒𝑠𝑡ℎ𝑒𝑡𝑖𝑐, 𝑎𝑝𝑝𝑎𝑟𝑎𝑡𝑢𝑠, 𝑜𝑟 𝑜𝑡ℎ𝑒𝑟 𝑡ℎ𝑒𝑟𝑎𝑝𝑒𝑢𝑡𝑖𝑐 𝑜𝑟 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑡𝑖𝑐 𝑠𝑢𝑏𝑠𝑡𝑎𝑛𝑐𝑒 𝑜𝑟 𝑡𝑒𝑐ℎ𝑛𝑖𝑞𝑢𝑒.
Diagnosing is strictly prohibited for unlicensed practitioners. Instead, they can facilitate communication between owners and the managing veterinarian or advocate for veterinary examination when issues arise.
While terms like “treat” are generally accepted in the human massage therapy realm, caution is advised as interpretations by a particular veterinary medical board may vary. Opting for terms such as “address” or “do a session” can mitigate risks.
Similarly, practitioners should refrain from using terms like “physical therapy” since this is a licensed title for human Physical Therapists. Even veterinarians use designations like “animal rehabilitation therapy” instead of “physical therapy”.
Certain terms, such as “chiropractic,” are also restricted to individuals with relevant qualifications. Practitioners must respect these boundaries and refrain from using terms like “manipulation” or “adjustment” unless properly authorized.
Despite the intricacies, awareness of these nuances can safeguard practitioners from accusations of overstepping their scope of practice.
𝐔𝐬𝐢𝐧𝐠 𝐒𝐎𝐀𝐏 𝐧𝐨𝐭𝐞𝐬 𝐟𝐨𝐫 𝐚 𝐜𝐥𝐢𝐧𝐢𝐜𝐚𝐥 𝐚𝐩𝐩𝐫𝐨𝐚𝐜𝐡
SOAP notes, a widely used method of medical record keeping and documentation for healthcare providers, can be a helpful way for practitioners to make sure that we are taking a clinical approach to our work and not skipping over important steps in the data collection process. SOAP is an acronym for Subjective, Objective, Assessment, and Plan.
Here is how veterinarians use SOAP notes:
The 𝑺𝒖𝒃𝒋𝒆𝒄𝒕𝒊𝒗𝒆 components include information collected from the owner or trainer such as the signalment (age, s*x, breed), presenting complaint, and medical and performance history.
The 𝑶𝒃𝒋𝒆𝒄𝒕𝒊𝒗𝒆 parameters are data collected by the veterinarian and may include vital signs, physical examination, laboratory tests, and diagnostic imaging.
The 𝑨𝒔𝒔𝒆𝒔𝒔𝒎𝒆𝒏𝒕 then involves the process of synthesizing the subjective and objective information to form a diagnosis.
The 𝑷𝒍𝒂𝒏 is then based on the diagnosis. So, if we do not do an assessment or only do a partial assessment, we are not able to place much confidence in our diagnosis. We did not do the work – if we have no gas in our car, then we can’t expect to go far. If we do not have a diagnosis, then how can we build a plan?
S leads to O leads to A leads to P. Results in focused and effective treatment for your patient.
P (treatment) without S or O or A. Results only in P (p*e). :-)
Space does not allow us to provide here an extensive list or detailed description of the subjective and objective outcome parameters needed to fully assess, for instance, the appendicular and axial skeleton in horses. However, here is a general outline of points that should be covered in a detailed musculoskeletal and neurologic evaluation:
𝐇𝐢𝐬𝐭𝐨𝐫𝐲
Signalment – age, s*x, breed, athletic discipline, exercise
Presenting complaint, review of body systems
Medical-surgical-performance history, current medications
𝐎𝐛𝐬𝐞𝐫𝐯𝐚𝐭𝐢𝐨𝐧
Static – environment, behavior, conformation, posture, body condition, symmetry
Dynamic – in the stall, at liberty in paddock, in hand, on lunge, tacking up, mounting, ridden
𝐏𝐚𝐥𝐩𝐚𝐭𝐢𝐨𝐧
Soft tissue – hair, skin, superficial fascia, deep fascia, ligaments, tendons, muscle, vasculature
Osseous – landmarks, prominence, size, shape, spacing
𝐌𝐨𝐛𝐢𝐥𝐢𝐳𝐚𝐭𝐢𝐨𝐧
Soft tissue – skin, fascia, muscle, tendon, ligament
Articulations – low vs. high motion, types of articulations (hinge, complex), arthrokinematic vs. osteokinematic
𝐍𝐞𝐮𝐫𝐨𝐥𝐨𝐠𝐢𝐜 𝐚𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭
Cranial nerves – mental status, behavior, head tilt
Sensory – light touch, pin prick, stroking vs. pressure, posture, proprioception
Motor – strength, coordination, spasticity, tail pull, tail tone
Reflexes – deep tendon, spinal (sternal elevation, lumbosacral flexion)
Because non-veterinary practitioners do not “diagnose”, they typically adapt SOAP notes to their needs. Although different practitioners may use different session forms, these forms should all include the initial history (signalment including the client’s concerns and goals) plus static and dynamic observations that map how the horse presents regarding any asymmetries in structures, muscles, or movement. For soft tissue palpation, the “Four Ts” of bodywork are employed – which include comments regarding tone, texture, tenderness and temperature.
𝐇𝐞𝐫𝐞 𝐢𝐬 𝐡𝐨𝐰 𝐧𝐨𝐧-𝐯𝐞𝐭𝐞𝐫𝐢𝐧𝐚𝐫𝐲 𝐩𝐫𝐚𝐜𝐭𝐢𝐭𝐢𝐨𝐧𝐞𝐫𝐬 𝐨𝐟𝐭𝐞𝐧 𝐢𝐧𝐭𝐞𝐫𝐩𝐫𝐞𝐭 𝐭𝐡𝐞 𝐒𝐎𝐀𝐏 𝐚𝐜𝐫𝐨𝐧𝐲𝐦:
The Subjective section of the session form includes the practitioner’s impressions and opinions based on personal experience (or based on what the owner tells you).
Findings from the static and dynamic assessments are included in the Objective section, with no personal impressions added.
Remember that practitioners must avoid diagnosing. For example, instead of stating that the cranial swing phase of the right forelimb is shorter than that of the left forelimb – which is a fair and objective comment – if the practitioner then adds “because of possible navicular syndrome,” that would be considered diagnosing.
The “A” section is often interpreted as Action, i.e., what the practitioner did during the session, including reassessment at the end of the session, to note improvements.
The Plan section of the form includes recommendations to the client for exercises, plus the practitioner’s thoughts regarding future sessions with that animal.
It goes without saying that when a horse is under active veterinary care, the session should be cleared first with the veterinarian to make sure the work is appropriate for the animal. Any suggestions by the practitioner for animals under active veterinary care should also be discussed with the managing veterinarian.
𝐌𝐞𝐚𝐬𝐮𝐫𝐢𝐧𝐠 𝐨𝐮𝐭𝐜𝐨𝐦𝐞𝐬
Our March 2024 blog post and Community Gathering, on the effectiveness of manual therapies, addressed how we can measure the success of our work. Suffice it to say here that unless we adequately assess our patients prior to treatment, we will not have a baseline or reference point with which to compare our results (i.e., measure our effectiveness). Specific performance indicators can be used to assess our treatment efficacy, which will vary according to our intent for providing care.
𝐈𝐧 𝐜𝐥𝐨𝐬𝐢𝐧𝐠...
From a veterinarian perspective, the treatment is only as good as the diagnosis, and the diagnosis is only as good as the assessment. For all practitioners, the quality of our assessment defines the quality of our patient care.
If you are a practitioner who has been taught appropriate assessment protocols, this blog post may serve as a gentle reminder of the importance of always taking the time to perform a thorough assessment and of constantly reassessing your work.
If your training did not provide sufficient methods to allow you to complete a whole-body evaluation, then we encourage you to seek out additional educational opportunities.
If you are contemplating training as a manual therapist, make sure that you contact the certification programs you are considering to ask about the breadth and depth of the assessment protocols that they teach in the didactic or practical portions of their course.
If you are an animal owner, always ask the practitioner to perform an appropriate assessment prior to working with your animal and to explain their findings. Although non-veterinary practitioners are not legally allowed to use the term “diagnosis” – this term is reserved for veterinarians – they should absolutely be willing and able to share their “findings” and their treatment plan. And, of course, advise you if they think that your animal needs to be referred to a veterinarian, a different practitioner, or other member of the animal’s care team.
