During my outpatient neuro prac, patient appointments were booked back-to-back and patients were expected to be treated for the full 90 minutes. This left no time for me to write up a SOAPIER at the end of each treatment session. After the last patient had finished, there were 30 minutes left for cleaning up the treatment area and writing notes. Given that I saw 4 patients a day, it was really insufficient! The clinic had a rule that notes were to be written within the same week, and I found myself staying back on Friday afternoons (we had half day off on Friday) to catch up with my notes.
Writing notes at the end of the day and week affected the accuracy of my notes. I would get muddled up about the reps/sets or evaluation of each patient’s treatment and sometimes memory lapses were filled with guesswork. To cope with this, I tried carrying a notebook around with me so that I could jot down the treatment details. As I was bringing the notebook home, I had to be careful not to breach any confidentiality issues by using patient initials.
I wonder if I have a short-term memory problem, or if anyone else has had difficulty in this aspect. Any tips to improve the system or the way I could work would be much appreciated too!
2 comments:
Hey Steve, I know how you feel. Im terrible at remembering detail but i think its just practice and i hope that none of us have a short term memory problem. I use the idea you already mentioned but using a little book and jotting done the stuff i do with each patient during each treatment. I just use initials so therefore there is no confidentiality broken. I really don't know what other ideas to give to you. I guess its a bit of trial and error to find what works for you but I honestly I believe it will come to us and we will be able to remember whatever we need!!
Hey Steve, I have just started my prac where you were! Aftyer my first week I have encountered the same problem, staying back until 3pm on my half day writing notes:( I was hoping it was just because it was the first week and I had been observing my supervisor in all my spare time leaving me no time to catch upo on notes and that things would be easier to manage in the coming weeks..but I guess not! I have been using the notebook like you have and think that I am just going to have to cut into my precious lunch hr evry few days to write up my notes because I really would like my friday afternoon back!
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