Documenation

Reasons to Document

Medical Record & Notes

Medical Record & Notes
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"S" = Subjective

"S" = Subjective
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"O" = Objective
What went on during treatment.
Chronologically if necessary.

"O" = Objective
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"O" = Objective
COMMON MISTAKES

"A" = Assessment

"A" = Assessment
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"P" = Plan

Functional Maintenance Program

Informed Consent

Medical Necessity

Negative Prognostic Indicators

Positive Prognostic Indicators

Restorative Programs

Screening

Standardized Assessments