By G. Kettenbach
An amazing source for any health professional wanting to profit or increase their talents with easy, ordinary motives of the hows and whys of documentation. It additionally retains speed with the alterations in actual remedy perform this present day, emphasizing the Patient/Client administration version. part by way of part, workout by way of workout, the 4th variation may also help you to to jot down transparent, concise, and proper sufferer care notes utilizing a number of instruments, together with cleaning soap notes.
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Additional resources for Writing Patient Client Notes: Ensuring Accuracy in Documentation, Fourth Edition
O. Dr. Smith/Janice Jones, OTR 3. In PT note: Rx: AROM R ankle bid 4. In chart in doctor’s initial note: imp: COPD; R/O lung CA 5. Physician’s orders: Record I&O; all meds per IV; NPO; transfer Pt. to ICU Translation: The patient has a history of hypertension, arteriosclerotic heart disease, congestive heart failure, myocardial infarction in 2005, transient ischemic attack in 2006. Translation: Up at discretion (patient’s discretion) Aspirin every 4 hours Bathroom privileges when necessary Nothing by mouth after midnight Verbal order given by Dr.
12. Medical dx of S/P sprain R ankle 4 wks. 13. Rates pain as 4 on a 0–10 scale (0 = no pain). 14. Female 15. Has not received any Rx of this R ankle sprain other than splinting. 16. Hx of 3 previous R ankle sprains & 2 previous R wrist sprains. 17. Caucasian c h a p t e r 5 The Patient/Client Management Note: Writing History 33 18. ’s recreational activities in middle school; unable to participate in after-school art activities due to pain level at end of day. 19. Pt. wants PT to help her to be able to amb.
S daughter states Pt. lives in assisted living situation because Pt. falls frequently & needs help c¯ transfers at times. Current Condition: Pt. states she believes the pain in her foot is caused by her back. Abbreviations and Medical Terminology Appropriate abbreviations and use of medical terminology are expected. Correct spelling is necessary for the therapist to be represented appropriately as a professional. The most concise (yet clear) wording should be c h a p t e r 5 The Patient/Client Management Note: Writing History used.