Incomplete or Inaccurate Assessments
Some therapists fail to fully integrate the subjective and objective findings into a meaningful assessment. For instance, simply stating "Patient is improving" does not give enough context. The assessment should reflect the patient's progress, changes in condition, or factors influencing their treatment.
Tip: Use the assessment section to synthesize the data, identifying trends, risks, and treatment adjustments. Ensure it addresses whether the patient is improving, worsening, or plateauing.