TY - CHAP M1 - Book, Section TI - Documenting the Examination A1 - Kettenbach, Ginge A1 - Schlomer, Sarah L. A1 - FitzGerald, Jill PY - 2016 T2 - Writing Patient/Client Notes AB - When a therapist sees a patient for the first time, the therapist performs a comprehensive examination of the patient. The information gathered in the examination, in combination with clinical judgment, allows the therapist to determine the diagnosis, prognosis, and plan of care for the patient,1 so documenting the results of the examination is a critical component of documenting patient care. SN - PB - F. A. Davis Company CY - New York, NY Y2 - 2024/03/29 UR - fadavispt.mhmedical.com/content.aspx?aid=1180749329 ER -