Describe the core elements of documentation in the medical record.

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 difference 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?
• Why is it important to know a client’s medical history?
• How does documentation support services provided (e.g., billing, plan of care)?