![]() ![]() Summarize and relate the patient’s statements (from the subjective section) to the patient’s overall progress, your interventions and the plan for future PT sessions.Include statements about the patient’s overall progress o(or lack of progress) towards their goals.For now, appreciate that this is where we: Given the importance of the assessment section, we will be spend much more time on its development in a subsequent chapter. We use the Assessment section to offer that rationale. ![]() For now, let’s just say that Defensible Documentation refers to the notion that our documentation should be presented in a way as to explain the rationale for all of our treatment interventions and our responses to our patient’s ever-changing status. In class, we will be discussing something called “Defensible Documentation”. To justify care, we need to explain why the selected interventions were used and how they are (or not) helping the patient achieve their goals. This is the most challenging part of the note for all of us student to experienced clinician. The ASSESSMENT section is where we provide an interpretation, analysis and our professional judgment of the patient’s overall performance and response to PT. You will need to be sure where you will be signing your entries on these forms - always check with your CI or PT.This form of documentation may also have an area to write a narrative.Typically, the PT or PTA will document note not only the reps, sets and position of the patient on the flow sheet, but if the patient needed any assistance (and what type) as well.The flow sheet is not a substitute for the SOAP note, but rather it is a separate (hard copy / paper form) supplement the actual note.Flow sheets are used to record the patient’s therapeutic exercises or maybe modality use.Sometimes the objective data related to a patient’s exercise plan is kept in a separate location in the PT gym and is recorded on a paper log referred to as a Flow Sheet.
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