Note Writing and the Process of Clinical Decision-Making

|Download (.pdf)|Print

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

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.

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.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Note Writing and the Process of Clinical Decision-Making

Citation

Jump to a Section

References

Pop-up div Successfully Displayed