writing other notes
DESCRIPTION
Writing Other NotesTRANSCRIPT
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)