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

These elements are taken from APTA's Guidelines: Physical Therapy Documentation of Patient/Client Management.

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