0 points
(N/A)
65-74 point
75-79 points
80-89 points
90-100 points
Client's perception of the treatment being received, the progress limitations, needs and problems. Addresses pain.
Observations of the treatment being provided. Contains all the measurable, quantifiable, and observable data. Includes CPT code(s), time spent during treatment.
Therapist interpretation of the meaning of the events reported in the objective section. Includes functional limitations along with expectations of the client's ability to benefit from therapy. Contains an explicit statement of progress or lack of progress.
What the therapist plans to do next to continue with the goals and objectives in the treatment plan. Includes anticipated frequency and duration.
Use of electronic health/medical records (EMR), spelling, grammar, therapist signature.