1. Documentation Waleed Al-Shehri,BSc.PT King Saud university College of applied Medical Science Rehabilitation Science Department Physical Therapy

2. Why ? For communication with other health team. Legal document. Used in the patient's record for review and quality control. Continuing Evaluation. Researches.  POMR

3. POMR Problem Oriented Medical Record. Weed & Zimny. Four Phases. Treatment Process DatabaseImpairmentsPOC Patient Progress

4. SOAP Note

5. Initial Evaluation Progress Notes Discharge Summary

6. Initial Assessment

7. Subjective General Data. Description of Problem. History of Present Problem. Past Medical History. Psycho-Social History.

8. Objective Observation. Physical. Cognitive. Behavior. Measurable Terms.

9. Assessment Problem List Short-term Goals Long Term Goals Impressions or Summary

10. Problem List 1.Review the S and 0 portions of the note, jotting down or highlighting findings that are not WNL and that can be influenced or changed by rehabilitation. (Medical or psychiatric problems do not belong in the rehabilitation problem list.) 2. Set priorities as to which problem is the most important, the next important, and so forth. 3. List the problems to be addressed during rehabilitation in order of priority.

11. Short-term Goals 1. Are the steps along the way to achieving long- term goals. 2. Are based on the long-term goals. 3. Serve as the basis for treatment planning. 4. Components of short-term goals are the same as those of long-term goals.

12. Long Term Goals 1. State the long-term outcomes of rehabilitation. 2. Are based on the problem list. 3. Are the bases for setting short-term goals.

13. Goal AchievableTimedMeasurableSpecificReliable

14. Impressions or Summary Can include any of the following types of information: a. Correlations between the subjective and objective information in the note. b. Justification for the goals and/or treatment plan. c. Clarification of the patient major problems. d. Justification for further treatment.

15. Impressions or Summary e. A discussion of the patient progress (or lack of progress) in rehabilitation. f. A discussion of the patient rehabilitation potential and why. g. An explanation of any difficulties in obtaining information during the initial assessment and testing. h. Suggestions for further testing/treatment needed.

16. Plan must include the following information: A. Frequency per day or per week that the athlete will be seen. B. Treatment the patient will receive. C. Location of the treatment. D. The treatment progression. E. Plans for further assessment or reassessment.

17. Plan F. Plans for discharge. G. Athlete and family education. H. Equipment needs and equipment ordered for/sold to the patient. I. Referral to other services; if there are plans to consult with the patient’s physician regarding further treatment or referral.

18. Progress Notes

19. S (Subjective): Includes updates or additional information. O (Objective): Update or add to the information reported in the initial note or last interim note. A (Assessment): Refers to the short-term goal(s) achieved and new short-term goal(s) set. If a short-term goal has not yet been achieved, the notes tell the reason why the goal has not been achieved. P (Plan): The treatment plan will need to be revised as the patient's condition is reassessed and new short-term goals are set.

20. Discharge Summary

21. S (Subjective): Completely summarizes the patient’s complaints, home situation, whether the patient feels the goals set were achieved or not. O (Objective): Completely summarizes the patient’s condition upon discharge from the facility (more similar to the initial note in format and length). A (Assessment): comments are made on the most recently set short-term goals and why they were or were not achieved.

22. P (Plan): 1. Overview of treatment. 2. Home program instructions given. 3. Other types of instructions given. 4. Any type of equipment sold to the patient. 5. Referral to a home health agency or any other professional. 6. The number of times the patient was seen. Discharge Summary

23. 7. If and when the patient was not seen, on hold and why. 8. Any instances of the patient skipping or canceling treatment sessions. 9. To where the patient is discharged. 10. The reason for discharge. 11. Recommendations for follow up treatment or care given to the patient. Discharge Summary

24. Don’t Forget ! Every session. Don’t Use abbreviations. The language should be easily understood by all. Writing the SOAP immediately after The session. Signature. Errors must be crossed through with a single line.

25. Thank You