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.
The assessment is too vague e.g.
"Patient is improving"
...little insight is provided here!
- 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
When you are ready, please proceed to the objective assessment of your patient.