ch. 1. Introduction to note writing
ch. 2. Writing in a medical record
ch. 3. Medical terminology
ch. 4. Using abbreviations
ch. 5. The patient / client management format : history
ch. 6. The patient / client management format : writing systems review
ch. 7. The patient / client management format : documenting tests and measures
ch. 8. The SOAP note : stating the problem
ch. 9. The SOAP note : writing subjective (S)
ch. 10. The SOAP note : writing objective (O)
ch. 11. Writing the diagnosis note
ch. 12. Writing the prognosis
ch. 13. Writing expected outcomes (long-term goals)
ch. 14. Writing anticipated goals (short-term goals)
ch. 15. Documenting planned interventions
ch. 16. Applications and variations in note writing
ch. 17. Alternatives : documentation forms, medicare forms, and computerized documentation.
