The physiotherapy diagnostic assessment: content, methods and reporting

The physiotherapy diagnostic assessment: what it is

The physiotherapy diagnostic assessment — in France the bilan diagnostic kinésithérapique (BDK) — is the structured examination a physiotherapist carries out before starting rehabilitation. It is not paperwork: it turns a medical prescription (rehab for low back pain, a post-op knee) into an individualised care plan with measurable goals.

From the medical diagnosis, the physiotherapist forms their own physiotherapy diagnosis: an analysis of impairments, activity limitations and participation restrictions. This mirrors the World Health Organization's International Classification of Functioning (ICF), which separates the damaged structure, the altered function and its impact on daily life.

The medical diagnosis says what the patient has; the physiotherapy diagnosis says how it limits them and what to work on.

What is it for?

• Guiding treatment: it prioritises targets (pain, stiffness, weakness, balance).
• Providing a baseline: initial measures make progress objective.
• Communicating with the referring doctor: the summary documents the starting point, goals and results.
• Securing the decision: it can reveal signs that fall outside physiotherapy and warrant referral back to the doctor.

What a complete assessment contains

A thorough assessment combines a subjective interview with an objective examination. Before any measurement, the physiotherapist also observes posture, the way the patient moves and any limping, and palpates painful or tense areas — qualitative findings that give meaning to the figures collected next.

History taking

It starts with the history: onset, past conditions, current treatments, lifestyle, work and sport, and the patient's expectations. The functional complaint — what the patient can no longer do — drives the goals.

Range of motion

Goniometry measures joint range (flexion, extension, rotation) with a goniometer. Compared with the healthy side or reference values, it objectifies stiffness and gives a reproducible figure from session to session.

Muscle testing

Strength is graded on the familiar 0–5 scale, where 0 is no contraction and 5 is normal strength against resistance. Simple and widely shared, it tracks strengthening over the weeks.

Pain assessment

Pain is measured with validated scales — the Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS), 0 to 10 — along with its type and triggers.

Standardised functional scales

Beyond analytic measures, standardised functional scales capture real-world impact: reproducible, comparable over time and clear to the referring doctor.

| Scale | What it assesses | Typical area | |---|---|---| | Berg | Static and dynamic balance | Older adults, neurology | | Tinetti | Balance, gait, fall risk | Geriatrics | | Quick-DASH | Upper-limb disability | Shoulder, elbow, hand | | VAS / NRS | Pain intensity | Any setting |

The right scale depends on the region and the goal, and other tools exist too — quality-of-life indices, timed walking tests or region-specific disability questionnaires. What matters is choosing a validated tool, using it the same way each time and keeping the score so measures stay comparable over the weeks.

Structuring the summary for the referring doctor

The summary sheet should follow a constant template: context (prescription, diagnosis, date), initial findings with figures, physiotherapy diagnosis, short- and mid-term goals, treatment plan, and re-assessment criteria. A clear, dated, quantified summary supports dialogue with the prescriber and justifies any extension request.

Traceability and progress tracking

A BDK only has value if it is re-assessed. Repeating the same measures at intervals turns clinical impressions into objective data: range regained, pain falling, functional score improving. This is where practice-management software saves real time — centralising assessments, comparing measures, visualising progress and generating reports. Tools like Cabdivin structure this follow-up without adding admin, alongside the rest of practice management.

Key takeaway

The physiotherapy diagnostic assessment is the backbone of care. Combining history, goniometry, muscle testing, pain assessment and standardised functional scales, it sets a solid physiotherapy diagnosis, measurable goals and a usable summary for the doctor — with regular re-assessment to prove progress. For physiotherapists, Cabdivin simplifies this: structured records, comparable measures, progress curves and assisted reports. Free 14-day trial, no credit card required.