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4 Cards in this Set
- Front
- Back
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Documentation How Why Document content |
Right eye S o a p Document Impairment Functional limitations Disability. Icf Why 1. Quality assurance 2. Research and education 3. Reimbursement Q |
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S o a p notes |
S subjective Hx What patient says complaint House situation env barrier nose hair Pts Goal eye Objectve observation Your Arom strength transfer Lips Into categories Assessment the problem list Dependence in transfer, amb Less strength Less ROM Related to s and o 2. Long term goals and functional outcome Increase ROM from 0-180 in 2 weeks in order to have independent movement 3.Short term goal 4. Summary Pt has difficulty in learning home exercise program despite written handout. Review needed Plan 1. For short term goal Modality 2. Long term goal |
