Documentation Continued: Goal Creation, Progress Notes, and Discharge Summaries

Laurie Knis-Matthews, Ashley N. Fuentes

Research output: Chapter in Book/Report/Conference proceedingChapterpeer-review

Abstract

The previous chapter introduced the basics of effective documentation along with a deeper understanding of the evaluation summary using the POP format. This chapter will continue discussing effective documentation following the POP format for evaluation summaries with specific information about long-and short-term goal creation or the plan. Goals are a central part of documentation as it represents an opportunity to measure a person’s progress during intervention and form the basis for other forms of documentation such as progress notes and discharge notes. Other forms of documentation will also be introduced in this chapter.

Original languageEnglish
Title of host publicationMatthews Model of Clinical Reasoning
Subtitle of host publicationA Systematic Guide to Occupation-Based Evaluation and Intervention Planning
PublisherTaylor and Francis
Pages127-138
Number of pages12
ISBN (Electronic)9781000965506
ISBN (Print)9781032491615
DOIs
StatePublished - 1 Jan 2023

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