Intro to Documentation Flashcards

1
Q

What are the 3 principles of note writing?

A

Accuracy
Brevity
Clarity

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2
Q

What are the 4 types of notes PTs write?

A

Initial note/eval
Daily note
Progress/re-eval
Discharge

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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)

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