After the physical therapist examines the patient, the next step in the process of completing the initial evaluation is to take all of the information previously gathered in the History, Systems Review, Tests and Measures, and Review of Systems of the Patient/Client Management Note (or the Problem, Subjective, and Objective sections of the SOAP Note), and formulate the Assessment section of the note. This process includes mentioning and linking the patient's impairments, activity limitations, and participation restrictions as they relate to the patient's reason for referral. This process then continues by pairing information from the Evaluation with clinical reasoning and judgment to formulate the patient's physical therapy diagnosis and prognosis as they relate to the reason for referral to physical therapy, thereby completing the Assessment section of the note.
Part IV of this book covers the three sections that form the Assessment portion of the note: Evaluation (Chapter 16), Diagnosis (Chapter 17), and Prognosis (Chapter 18). Although the information is the same, the manner in which that information is divided up in the two note formats differs slightly. The Patient/Client Management Note has three sections, called Evaluation, Diagnosis, and Prognosis. In the SOAP Note, the Evaluation, Diagnosis, and Prognosis parts of the note are listed in a section called the Assessment (A). In some facilities, the expected outcomes and anticipated goals are also listed in the Assessment part of the note; for the purposes of this text, they are listed as part of the Plan of Care (P) (see Chapter 19).