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) OR SOAP Note 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 |