First clinical rotation and documentation

[DPTPT]

Hello everyone I will be starting my first clinical internship in the fall. Something I’m worried about is if i get placed (I have not been placed yet) in a fast pace clinic and then worried about forgetting all the details of what exercises I have done with the patients.

Would it look bad to my CI if I quickly write down what I did with the pt on a notepad when I can so that documentation can be a bit easier for me ? I feel like Im Guna have trouble remembering everything I did esp since it’s my first internship and I’m guna be all nervous and stuff too in the beginning.

I would appreciate any advice about documentation for first internship! Thank you

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[Louisiana2018]

I worked as a tech in the acute care setting where a new patient was seen about every 30 minutes. The therapists would print out their patients list for the day and then after each treatment take 1-2 minutes to quickly jot down what they did with the patient and how they performed. I doubt they will require you to see 8+ patients and never jot down what you did with each one. If they don’t have lists like this, I would say feel free to use your own paper but to properly discard it (shred box) as it would potentially have patient identifies on it such as name or room number. And verify before taking any notes like that out of the setting (such as needing to document at home).

 

[ya1]

Of course write down what you do with patients. No need to memorize all that stuff.

 

[antochí]

In my final OP rotation, I kept a tiny notepad in my pocket to jot enough down to remember what I wanted to document later. One of the PTs on staff kept a few small post-its on the back of her badge for the same purpose in the IP side of the clinic, which I thought was brilliant.