I had a different CI today, so it was interesting to work with someone different and see different areas/patient populations today. I arrived in the morning, so I was able to watch my CI do her chart review. I tried to take as many notes as possible on the patients that we were going to see that day. I asked a lot of questions about what she was looking for in the chart and she slowed down a bit to explain things to me.
It was interesting to see how she was able to manage her caseload, such as deciding to see certain patients first or waiting to see some patients until the afternoon. Often times the patients will be out of their rooms for testing, will be seen by other professions, or might be eating their meals, so the therapist has to work around all these schedule changes to try to see as many patients as possible.
I also realized that I feel somewhat uncomfortable when I am left alone with patients while the therapist is outside the room for a few minutes, because I am usually unsure of how to start a conversation.
SOAP notes are a bit frustrating to write. There are a lot of abbreviations to use, it can be challenging to phrase things properly, it’s hard to remember what to write in each section, and then it’s difficult to write everything in an order that makes sense. We just began documentation so it will take time to get better at this skill, but I don’t like how I feel like I’m slowly progressing.
I jot notes during each patient’s treatment so I don’t forget when I write the notes later. Then I write a rough draft of the entire note, edit that note by making lots of scribbles and drawing arrows when I want to reorder things, and then rewrite the entire note. It takes me about an hour to write one note, so I’m in awe when I see others completing their notes so quickly.