My Clinical Experience So Far…

• I have made a full Initial Evaluation of my

Patient! ☻– Congratulations!!!

• What you might really mean is…

–HAPIT NA KO MAHUMAN SA KAPOY NA

‘DOCUMENTATION’!!! ☻☻☻

Sorry to burst your ‘Joy Bubble’, but…

• Completing a patient’s Initial Evaluation (IE) is the start of the continuing patient management cycle…

So far you have undergone the following elements of Patient/Client

Management…• Examination• Evaluation• Diagnosis• Prognosis (including Plan of Care)• Intervention (the planning part… not yet

the actual intervention)

But remember…

• The elements of patient/client management belong to a CYCLE!!!– Once you go back to the Examination

part, this is now called…

When going through the cycle…

• You will be doing other documentation…

Writing Other Notes

In this topic…

• You will be able to…– Differentiate amongst the types of patient

care documentation.– Practice writing other documentation.

Types of Documentation

• 4 main types– Evaluation notes– Treatment notes– Turnover notes– Termination notes

Evaluation Notes

• 3 types– Initial Evaluation (IE)– Progress Notes (PN)– Re-evaluation (RE)