Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ Table Graphic Jump LocationFavorite Table | Download (.pdf) | Print Note Writing and the Process of Clinical Decision-Making Patient/Client Management Note Patient/Client Management Process SOAP Note History (includes Review of Systems) Systems Review Tests and Measures EXAMINATION Problem Subjective (includes Review of Systems) Objective (Systems Review and Tests and Measures) Evaluation Diagnosis Prognosis EVALUATION A (Assessment) includes: Evaluation Diagnosis Prognosis Expected Outcomes Anticipated Goals Interventions, including Patient Education PLAN OF CARE Plan of Care Includes: Expected Outcomes (in some facilities, included under A) Anticipated Goals (in some facilities, included under A) Interventions, including Patient Education OUTCOMES (re-examination and re-evaluation occur and another note is written at the time of re-examination and re-evaluation) + References Print Section ++ +1. +Principles of physical therapist patient and client management. Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Accessed online at http://guidetoptpractice.apta.org/content/1/SEC2.body on March 10, 2015. +2. +American Physical Therapy Association: Defensible Documentation for Patient/Client Management. Alexandria, VA: American Physical Therapy Association; 2009. Accessed online at http://www.apta.org/Documentation/DefensibleDocumentation/ on March 10, 2015.