ubjective assessment

What did you discover?

This is potentially the most important legal note because this is the therapists professional opinion in light of subjective and objective findings. It should explain the reasoning behind all decisions taken and clarify and support the analytical thinking behind the problem-solving process. How you arrived at the stated goals should be indicated, as well as any factors that may require modification, such as frequency, duration or intervention itself. Adverse, as well as positive responses should be documented.

Common errors:

The assessment is too vague e.g.

"Patient is improving"

...little insight is provided here!

Essentially:

document the diagnosis you arrived at
include causes of the diagnosis
Red flag anything to be aware of (we need to treat patient holistically) note any inconsistencies

Proceed?

When you are ready, please proceed to the objective assessment of your patient.

Objective Assessment

Note-taking

Keeping a clear record

Potentially the most important legal requirement, this Patient Record Form is the therapist's professional opinion in light of subjective and objective findings. It needs to explain the reasoning behind any decision taken and clarify all analytical thinking behind the problem-solving process. How did you arrive at your stated goals?
Also indicate any factors that may require further modification, such as frequency, duration or intervention itself. Document adverse, as well as positive, responses.

Common errors:

An assessment such as "patient is improving" is too vague since no insight is provided!

Essentially:

Document the diagnosis you arrived at
Include causes of the diagnosis
Red flag anything to be aware of (we need to treat patient holistically) and note any inconsistencies

The Form

The Patient Record Form is blank and, once printed, is completed by hand.

Standard Patient Form

Condensed Patient Form (less writing space)

(further notes on how to use your form)

Proceed?

When you are ready, please proceed to the subjective assessment of your patient.

Subjective Assessment