RT Book, Section
A1 Kettenbach, Ginge
A1 Schlomer, Sarah L.
A1 FitzGerald, Jill
SR Print(0)
ID 1135090386
T1 Note Writing and the Process of Clinical Decision-Making
T2 Writing Patient/Client Notes
YR 2016
FD 2016
PB F. A. Davis Company
PP New York, NY
SN 9780803638204
LK fadavispt.mhmedical.com/content.aspx?aid=1135090386
RD 2024/04/16
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)