Dr. S. had become increasingly active on the staff of a comprehensive rehabilitation hospital. He was particularly interested in geriatric rehabilitation, becoming the most frequent admitter of older patients to the facility. With the encouragement of the Chief of Staff and the administrator of the hospital, he began having meetings with the staff to discuss ways to improve the care of older rehabilitation patients. One of the ideas he presented to the group, which was made up of physicians, nurses, speech—language pathologists, occupational therapists, physical therapists, recreational therapists, social workers, case managers, and dieticians, was to have providers document their portions of the initial assessment in a single unified section of the chart and to put all progress notes within another single unified section using a goal-oriented, rather than a problem-oriented (SOAP), format.
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