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.