TY - CHAP M1 - Book, Section TI - Note Writing and the Process of Clinical Decision-Making A1 - Kettenbach, Ginge A1 - Schlomer, Sarah L. A1 - FitzGerald, Jill PY - 2016 T2 - Writing Patient/Client Notes AB - Table Graphic Jump Location|Download (.pdf)|PrintNote Writing and the Process of Clinical Decision-MakingPatient/Client Management NotePatient/Client Management ProcessSOAP NoteHistory (includes Review of Systems)Systems ReviewTests and MeasuresEXAMINATIONProblemSubjective (includes Review of Systems)Objective (Systems Review and Tests and Measures)EvaluationDiagnosisPrognosisEVALUATIONA (Assessment) includes:EvaluationDiagnosisPrognosisExpected OutcomesAnticipated GoalsInterventions, including Patient EducationPLAN OF CAREPlan of Care Includes:Expected Outcomes (in some facilities, included under A)Anticipated Goals (in some facilities, included under A)Interventions, including Patient EducationOUTCOMES(re-examination and re-evaluation occur and another note is written at the time of re-examination and re-evaluation) SN - PB - F. A. Davis Company CY - New York, NY Y2 - 2024/03/28 UR - fadavispt.mhmedical.com/content.aspx?aid=1135090386 ER -