RT Book, Section A1 Kettenbach, Ginge A1 Schlomer, Sarah L. A1 FitzGerald, Jill SR Print(0) ID 1180749329 T1 Documenting the Examination 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=1180749329 RD 2024/03/28 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.