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Initial Note Re-evaluation/Progress Note Daily Visit Note Discharge Note

Written after the initial examination/evaluation of a patient

Written 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 written

Written when therapy is discontinued or the patient is discharged from therapy

Patient/Client Management Note

  • History (includes Review of Systems)

  • Systems Review

  • Tests and Measures

  • Evaluation

  • Diagnosis

  • Prognosis

  • Plan of Care (includes Expected Outcomes, Anticipated Goals, Intervention Plan)



  • Problem

  • Subjective (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-evaluation

  • Change in Prognosis, as needed

  • Change to Plan of Care, including commentary on goals achieved, new goals set, and revised intervention plan

  • Subjective report from the patient about new or ongoing complaints/concerns, compliance with prior instruction, report of pain, and mitigating factors

  • Functional level of patient; includes impairments of body function and body structure, activities, and participation restrictions noted

  • Objective interventions provided/completed during that visit; includes frequency, intensity, and duration

  • Education provided and level of understanding of education; includes equipment education and level of independence with equipment

  • Patient's reaction to interventions/instruction provided/completed

  • If treatment was modified, reason for modifying treatment

  • Home program, home program progression, and level of independence with program

  • Communication with other health providers regarding the patient

  • The plan for the next patient visit (interventions, progression precautions)

  • Summary of History (or Problem/S)

  • Most recent re-evaluation results

  • Outcomes and goals achieved or not achieved (and reason not achieved)

  • Summary of interventions received

  • Final disposition of the patient

* All information here applies to both Patient/Client Management Notes and SOAP Notes

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