Intro to Documentation Flashcards
1
Q
What are the 3 principles of note writing?
A
Accuracy
Brevity
Clarity
2
Q
What are the 4 types of notes PTs write?
A
Initial note/eval
Daily note
Progress/re-eval
Discharge
3
Q
What is included in an initial note?
A
History, systems review, tests & measures (examination)
Plan of care - goals, interventions planned (evaluation, diagnosis, prognosis)