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Introduction

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This textbook has covered the reasons for writing notes and a brief history of the origins of the two note formats. It has offered the opportunity to practice writing the various types of notes along the way and to review and utilize medical terminology and abbreviations.

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As you begin to practice in clinical settings, you will find that each facility that uses the Patient/Client Management Note or SOAP Note format has its own variations of the format. Within any facility using a set note format, each therapist has his or her own variations of the format used by the facility. You will also note once you are in the clinic that not every facility that writes Patient/Client Management Notes or SOAP Notes includes every part of the note formats covered in this textbook. A few facilities include the Expected Outcomes and Anticipated Goals in the Assessnent portion of the note. Others combine the Assessment and Plan portions of the note and list each Expected Outcome, the corresponding Anticipated Goal(s), and Intervention Plans together before moving on to the next problem. There are as many variations in note writing formats as there are facilities that offer therapy.

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Applying the Patient/Client Management Note to Other Note Formats

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Facilities may elect not to formally use the Patient/Client Management Note format or they may use the format and not call it the “Patient/Client Management” format. No matter the format you may encounter, your knowledge of writing Patient/Client Management Notes should be helpful. Two examples of other note formats you may encounter in the clinic where this is helpful are letters to physicians or third-party payors and Individualized Education Programs (IEPs).

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Letters written to a physician's office on a regular basis are also usually organized in a particular style to save time. Certain categories are placed in a certain order, according to the standards set forth by the physical therapy practice involved. If you know the categories of the note formats taught in this textbook, you will be able to rearrange them to fit into a letter format. However, caution should be taken in using letters as a therapist's only documentation of care. Letters are not written after each therapy session, and letters are not considered true documentation of patient care. In today's busy outpatient clinical setting, most clinicians simply fax the most recent re-evaluation/progress note to the MD as this already contains all pertinent information regarding the patient's treatment, progress in therapy services, progress toward goals and any modifications to the goals if applicable, and the discharge plan for the patient.

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IEPs are used specifically in school systems. IEPs follow a standardized format that takes the information involved in the note formats taught in this textbook and renames and rearranges the categories. Goals that are set yearly become the Expected Outcomes. Whether or not they are officially written, Anticipated Goals ...

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