Title: Describe the core elements of documentation in the medical record.
Course: Physical/Occupational Therapy I (14060-I) > Section: Using Effective Communication in the Rehabilitative Environment

Description should include

- the medical record (electronic and/or print), such as precautions, medical history, and goal of treatment
- examples of documentation, such as SOAP notes (i.e., subjective, objective, assessment, and plan).

Process/Skill Questions:

- What is the distinction between subjective and objective information? How is each important in documentation?
- What are common precautions a therapy professional would look for before transferring a client?
- What is the importance of knowing a client’s medical history?
- How does documentation support services provided (e.g., billing, plan of care)?