What follows is a description of the main documentation elements of patient and client management: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary.

Please note that the Defensible Documentation offers additional guidance specific to pediatric patients and clients when protocols and practice may differ from managing adults. These sections are identified at the end of various sections throughout this resource.

Additionally, be sure to reference the companion article, Documentation: Risk Management, for related information.