Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management note : writing history -- The patient/client management note: writing the systems review -- The patient/client management note : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S) -- The SOAP note : writing objective (O) -- Writing the evaluation -- Writing the diagnosis -- Writing the prognosis -- Writing expected outcomes (long term goals) -- Writing anticipated goals (short term goals) -- Documenting planned interventions -- Overview of the medical record -- Legal aspects of the medical record -- Reimbursement -- Applications and variations in note writing -- Alternatives : documentation forms and computerized documentation -- The future : documentation using the ICF system
Summary
Suitable for health care professionals needing to learn or improve their skills, this book explains the hows and whys of documentation. It also coves changes in Physical Therapy practice, emphasizing the Patient/Client Management model
