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

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.