TY - CHAP M1 - Book, Section TI - Documenting the Evaluation/Assessment (A) A1 - Kettenbach, Ginge A1 - Schlomer, Sarah L. A1 - FitzGerald, Jill Y1 - 2016 N1 - T2 - Writing Patient/Client Notes AB - 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. SN - PB - F. A. Davis Company CY - New York, NY Y2 - 2024/03/28 UR - fadavispt.mhmedical.com/content.aspx?aid=1180749333 ER -