TY - CHAP M1 - Book, Section TI - Summary of Contents of the Four Types of Notes A1 - Kettenbach, Ginge A1 - Schlomer, Sarah L. A1 - FitzGerald, Jill Y1 - 2016 N1 - T2 - Writing Patient/Client Notes AB - Table Graphic Jump Location|Download (.pdf)|PrintInitial NoteRe-evaluation/Progress NoteDaily Visit NoteDischarge NoteWritten after the initial examination/evaluation of a patientWritten 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 writtenWritten when therapy is discontinued or the patient is discharged from therapyPatient/Client Management NoteHistory (includes Review of Systems)Systems ReviewTests and MeasuresEvaluationDiagnosisPrognosisPlan of Care (includes Expected Outcomes, Anticipated Goals, Intervention Plan)ORSOAP NoteProblemSubjective (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-evaluationChange in Prognosis, as neededChange to Plan of Care, including commentary on goals achieved, new goals set, and revised intervention planSubjective report from the patient about new or ongoing complaints/concerns, compliance with prior instruction, report of pain, and mitigating factorsFunctional level of patient; includes impairments of body function and body structure, activities, and participation restrictions notedObjective interventions provided/completed during that visit; includes frequency, intensity, and durationEducation provided and level of understanding of education; includes equipment education and level of independence with equipmentPatient's reaction to interventions/instruction provided/completedIf treatment was modified, reason for modifying treatmentHome program, home program progression, and level of independence with programCommunication with other health providers regarding the patientThe plan for the next patient visit (interventions, progression precautions)Summary of History (or Problem/S)Most recent re-evaluation resultsOutcomes and goals achieved or not achieved (and reason not achieved)Summary of interventions receivedFinal disposition of the patient* All information here applies to both Patient/Client Management Notes and SOAP Notes SN - PB - F. A. Davis Company CY - New York, NY Y2 - 2024/10/14 UR - fadavispt.mhmedical.com/content.aspx?aid=1180746637 ER -