RT Book, Section
A1 Kettenbach, Ginge
A1 Schlomer, Sarah L.
A1 FitzGerald, Jill
SR Print(0)
ID 1180746637
T1 Summary of Contents of the Four Types of Notes
T2 Writing Patient/Client Notes
YR 2016
FD 2016
PB F. A. Davis Company
PP New York, NY
SN 9780803638204
LK fadavispt.mhmedical.com/content.aspx?aid=1180746637
RD 2024/04/19
AB Table  Graphic  Jump  Location|Download  (.pdf)|PrintInitial  NoteRe-evaluation/Progress  NoteDaily  Visit  NoteDischarge  NoteWritten  after  the  initial  examination/evaluation  of  a  patientWritten  after  the  re-examination/re-evaluation  of  a  patient*Written  every  time  a  patient  is  seen  if  one  of  the  other  kinds  of  notes  is  not  writtenWritten  when  therapy  is  discontinued  or  the  patient  is  discharged  from  therapyPatient/Client  Management  NoteHistory  (includes  Review  of  Systems)Systems  ReviewTests  and  MeasuresEvaluationDiagnosisPrognosisPlan  of  Care  (includes  Expected  Outcomes,  Anticipated  Goals,  Intervention  Plan)ORSOAP  NoteProblemSubjective  (includes  Review  of  Systems)Objective  (includes  Systems  Review,  Tests  and  Measures)Assessment  (includes  Evaluation,  Diagnosis,  Prognosis)Plan  of  Care  (includes  Expected  Outcomes,  Anticipated  Goals,  Intervention  Plan)Results  of  subjective  and  objective  re-examination  and  re-evaluationChange  in  Prognosis,  as  neededChange  to  Plan  of  Care,  including  commentary  on  goals  achieved,  new  goals  set,  and  revised  intervention  planSubjective  report  from  the  patient  about  new  or  ongoing  complaints/concerns,  compliance  with  prior  instruction,  report  of  pain,  and  mitigating  factorsFunctional  level  of  patient;  includes  impairments  of  body  function  and  body  structure,  activities,  and  participation  restrictions  notedObjective  interventions  provided/completed  during  that  visit;  includes  frequency,  intensity,  and  durationEducation  provided  and  level  of  understanding  of  education;  includes  equipment  education  and  level  of  independence  with  equipmentPatient's  reaction  to  interventions/instruction  provided/completedIf  treatment  was  modified,  reason  for  modifying  treatmentHome  program,  home  program  progression,  and  level  of  independence  with  programCommunication  with  other  health  providers  regarding  the  patientThe  plan  for  the  next  patient  visit  (interventions,  progression  precautions)Summary  of  History  (or  Problem/S)Most  recent  re-evaluation  resultsOutcomes  and  goals  achieved  or  not  achieved  (and  reason  not  achieved)Summary  of  interventions  receivedFinal  disposition  of  the  patient*  All  information  here  applies  to  both  Patient/Client  Management  Notes  and  SOAP  Notes