Documentation. Chapters 7, 8, 9. Diagnoses, Functional Outcomes, Goals, & Rx Effectiveness. ASSESSMENT Provides the rationale for the necessity of the physical therapy medical treatment
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Chapters 7, 8, 9
Elements that support necessity of PT Rx
response and pt’s progress toward goals in
assessment component of progress note
Be cautious here !
before next session
*use future tense verbs
and researcher can not use pt name
*In all of these instances, PTA MUST follow rule of confidentiality!