ClinicNote Navigation​ &​ Clinical Writing​

Which of the following is part of an evaluation report?

• Reason for referral​​

• History & Background Information​

• Recommendations

• All of these

• Summary & Impressions​

True/False: It is okay to use standardized test abbreviations/acronyms in evaluation reports.

• True

• False

Which of the following is NOT something we typically consider when determining prognosis?

• Any ongoing medical or health concerns ​

• Previous level of function vs. Current level of function

• Motivation

• Amount of family support

• Success with other therapies or interventions

The acronym SMART in relation to goal writing stands for:

• Specific

  Measurable

  Abstract

  Realistic

  Timely

• Specific

  Measurable

  Achievable

  Relevant

  Timely

• Specific

  Measurable

  Achievable

  Rigid

  Timely

When writing goals, which of these should be considered?

• What do you want your client to do? ​

• How well do you want your client to do? ​

• How much help do you want to provide your client? ​

• How quickly do you want you client to do it?​

• All of the above.

The following goal is missing which component: By December 2021, the client will use the following grammatical structures during structured conversation with a peer or adult across 3 consecutive language sessions: regular and irregular past tense, regular and irregular plurals, and pronouns.​

• Specific

• Measurable

• Attainable

• Releant

• Time-based

Which of the following is a reason why it is important to write thorough but concise SOAP notes?

• 1. To justify payment for services

• 2. So the client knows what to expect next time

• 3. To facilitate improved patient care

• Both 1 & 3

How long should it take another clinician to read through a well-written SOAP note, in order to pick up treatment where it was previously left off?

• 2-3 minutes

• 5-8 minutes

• 10-12 minutes

• 15+ minutes

Describing the activity itself AND how it relates or how it was used to focus on your therapy goals is included in which part of the SOAP note?

• Subjective

• Objective

• Assessment

• Plan

True/False: Only relevant/useful information, or information that is abnormal should be included in the S section.

• True

• False