Assess Treat Record
Clinical workflow

From Assessment to Treatment Plan

Assess. Treat. Record. Reassess.

Assess Treat Record guides remedial massage therapists through a structured clinical workflow, helping connect assessment findings, treatment, reassessment, aftercare and the next treatment plan.

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Step 1

Select Your Client and Consultation

Start a new consultation within the client's clinical record so treatment information can remain connected over time.

Client Record
Sarah M. — Client since Jan 2024
Consultation #12 — 14 Jan 2025
Presenting: Neck stiffness and right shoulder pain, 2 weeks
Previous: Cervical ROM restricted — improved
Step 2

Record the Subjective Assessment

Document the client's presenting complaint, symptoms and other relevant information discussed during the consultation.

Subjective Assessment
Chief complaint: Neck stiffness, right shoulder pain
Onset: 2 weeks, gradual onset
Aggravating: Prolonged sitting, looking down
Relieving: Movement, heat
Step 3

Complete the Objective Assessment

Select the assessments relevant to the consultation and record your findings. Not every assessment applies to every client — complete what is clinically appropriate.

PostureRange of MotionCervical MovementShoulder MovementHip & Lower LimbSpecial TestsObjective Findings
Cervical ROM
Cervical flexion: 45° — reduced
Cervical extension: 40° — restricted
Cervical lateral flexion: 30° — restricted (right)
Cervical rotation: 55° — restricted (right)
Step 4

Select Areas and Muscles

Connect your assessment findings with the anatomical areas, muscle groups and individual muscles relevant to treatment.

Treatment Areas — Muscles
Area: Cervical & Shoulder
Upper trapezius
Levator scapulae
Sternocleidomastoid
Supraspinatus
Step 5

Document the Treatment

Record the areas treated, muscles addressed and treatment techniques used during the consultation. Structured selections keep your records consistent without requiring long free-text notes.

Treatment Record
Technique: Deep tissue massage
Technique: Myofascial release
Technique: Pin and stretch
Technique: Flush
Step 6

Reassess the Client

Record relevant changes following treatment and the client's response to the consultation.

Reassessment
Cervical flexion: 55° — improved (+10°)
Pain level: 3/10 (was 7/10)
Movement quality: Noticeably freer
Client response: Positive — less guarding
Step 7

Record the Outcome and Aftercare

Document the client's response to treatment and record relevant advice, stretches, exercises or other aftercare provided.

Aftercare & Outcome
Outcome: Client reports significant improvement
Stretches: Chin tucks, levator scapulae (daily)
Activity: 20 min walk daily
Advice: Screen height and posture review
Step 8

Create the Next Treatment Plan

Record what needs to be reviewed, reassessed or treated when the client returns.

Never start the next treatment from memory.

Your previous assessment, treatment, evaluation, aftercare and treatment plan remain part of the client's clinical story.

Next Treatment Plan
Reassess: Cervical ROM and shoulder flexion
Focus: Progress to shoulder mobilisation
Check: Upper trapezius response to treatment
Note: Forward head posture — monitor
The full clinical workflow

Assess → Treat → Record → Reassess → Plan

  1. 01
    Assess
  2. 02
    Treat
  3. 03
    Record
  4. 04
    Reassess
  5. 05
    Plan

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