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Initial Note


The problem part of the note contains information from the health record, which includes the following:

  • Medical diagnosis/present conditions/diseases affecting the present condition/treatment

  • Demographic information (patient's name, address, admission date, date of birth, biological sex, dominant hand, race, ethnicity, language, education level, advance directive preferences, referral source, and reasons for referral to therapy)

  • Recent or past surgeries affecting the present condition/treatment.

  • Past conditions/diseases affecting the present condition/treatment.

  • Medical test results affecting the present condition/treatment.

  • Medication list if you obtained this list from the patient's health record and not from the patient.


The Subjective part of the note contains information that the patient and/or significant others tell the therapist or assistant, such as:

  • Current conditions/chief concerns (Onset date of the problem, any incident that caused or contributed to the onset of the problem, prior history of similar problems, how the patient is caring for the problem, what makes the problem better and worse, and any other practitioner whom the patient is seeing for the problem.)

  • Prior and current level of function (The patient's previous level of function including activities and participation prior to the most recent onset of the current condition or complaint, current level of function including activity limitations and participation restrictions as a result of the current condition or complaint, and information about home management and community and work activities that apply to the patient's current situation or condition. If the patient has a chronic condition, this includes the level of function prior to the most recent onset or exacerbation of symptoms.)

  • Patient goals (The patient and sometimes family goals for therapy as told to the therapist by the patient or family/caretaker, in cases where the patient cannot speak for him/herself.)

  • Social history (Cultural and religious beliefs that might affect care, the person[s] with whom the patient lived prior to admission and will live after discharge, social support available to the patient now and that will be available after discharge.)

  • Employment status (Whether the patient works full time or part time, inside or outside of the home, is retired or is a student, and any special physical job requirements that the patient must be able to complete in order to return to full employment, such as needing to be able to lift at least 100 pounds.)

  • Physical environment and available resources (This includes assistive devices and equipment the patient uses or owns, the type of residence/building in which the patient lives/works/goes to school, the building environment, such as stairs or ramps available, and past use of community services, homemaking services, Meals on Wheels, hospice, mental health service, respiratory therapy, speech/language pathology. This may also include the availability and reliability of a caretaker after discharge.)

  • General health status (This includes the patient's rating of his own health and whether the patient has experienced any major life changes during ...

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