Efficient documentation in clinic

[darkangel77]

Hi guys!

So I recently began my first clinical affiliation at a Veteran's Administration hospital, a primarily subacute / outpatient setting. I was wondering if any of you guys had tips to share about efficient SOAP note documentation while in clinic?

Most of my patients I see on my own (my CI doesn't do anything, he only treats if the patient has a complicated case. Though he did help to orient me today), and I also have to take care of all the IEs, discharge, and progress notes, which have to be completed for all patients by the end of the day (he said we typically see between 12-15 patients within an 8 hour day). The girl that was helping to orient me (she had the affiliation in the previous time slot) wrote super detailed SOAP notes that always caused her to stay late, and I don't expect that my notes will be as detailed as hers (I prefer short and concise).

Any tips would be welcome! And thanks!

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[rcheeley]

You should include enough information in your note so that if another practicing PT had to treat this person on the next visit, they would know exactly what you did with that patient, how they responded, and what your thoughts on their ongoing POC should be based on your assessment of their current status. If someone had ANY questions regarding any of this information, then you're note was not sufficient.

On top of this information, if the patient is a medicare patient, you need to make sure to document medical necessity - such as current functional limitations, functional progression thus for, the need for continued treatment, and reasoning as to why this patient must see a PT to get this treatment (and not a personal trainer, massage therapist, etc).

Does that answer your question?

 

[rcheeley]

Hi guys!

So I recently began my first clinical affiliation at a Veteran's Administration hospital, a primarily subacute / outpatient setting. I was wondering if any of you guys had tips to share about efficient SOAP note documentation while in clinic?

Most of my patients I see on my own (my CI doesn't do anything, he only treats if the patient has a complicated case. Though he did help to orient me today), and I also have to take care of all the IEs, discharge, and progress notes, which have to be completed for all patients by the end of the day (he said we typically see between 12-15 patients within an 8 hour day). The girl that was helping to orient me (she had the affiliation in the previous time slot) wrote super detailed SOAP notes that always caused her to stay late, and I don't expect that my notes will be as detailed as hers (I prefer short and concise).

Any tips would be welcome! And thanks!

On another note. If your CI is not giving you any direction, and not supervising you directly and just letting you treat patients on your own (simple or not) then he/she is not doing their job correctly, ESPECIALLY if this is your first clinical rotation. You should be working "hand-in-hand" with your CI through your entire rotation, talking with and brainstorming with your CI on how best to examine, evaluate your examination findings, treat this patients functiona impairments, re-assess for functional progress, treatment effectiveness and possible changes needed in the POC, and then determine patient's appropriateness for D/C w/ HEP or further evaluation by the physician (or referral to another physician).

If you're CI is just letting you "do your own thing" and indirectly supervising you, then you are really missing out on a lot of your learning experience. I had 1 CI like this in one of my rotations and I really missed out on a lot of the learning experience and valuable insight I could have gotten from an experienced PT, instead I had to learn a lot of things the long way and through my "lack of experience."

I would talk to your CCCE (I think that's right) and look into a different placement or make sure another student doesn't get placed at that site. Otherwise you're only hurting yourself and future PT students.

 

[soccer31]

On another note. If your CI is not giving you any direction, and not supervising you directly and just letting you treat patients on your own (simple or not) then he/she is not doing their job correctly, ESPECIALLY if this is your first clinical rotation. You should be working "hand-in-hand" with your CI through your entire rotation, talking with and brainstorming with your CI on how best to examine, evaluate your examination findings, treat this patients functiona impairments, re-assess for functional progress, treatment effectiveness and possible changes needed in the POC, and then determine patient's appropriateness for D/C w/ HEP or further evaluation by the physician (or referral to another physician).

If you're CI is just letting you "do your own thing" and indirectly supervising you, then you are really missing out on a lot of your learning experience. I had 1 CI like this in one of my rotations and I really missed out on a lot of the learning experience and valuable insight I could have gotten from an experienced PT, instead I had to learn a lot of things the long way and through my "lack of experience."

I would talk to your CCCE (I think that's right) and look into a different placement or make sure another student doesn't get placed at that site. Otherwise you're only hurting yourself and future PT students.

Completely agree! This is your first clinical rotation, and you should not be going through all of it by yourself. I think your CI's approach would be appropriate if this was you last clinical, not first. I am sure when you talk to some of your classmates they are probably not doing as much as you are, but they are (or should be I would say) within close supervision of their CIs, and that is what you want during your first clinical. I believe that developing yourself into a good clinician take steps, and skipping some of those can be detrimental at the end.

 

[MinnDasota]

I'm with the last 2 posts. On your first affil, you should be learning/training along side your CI.

 

[PT Dad]

Does your school require you to do an evaluation of your clinical experience? My daughter has to do that in order to provide feedback to the clinical program director. I would shoot of an email to the director at your school to see if the situation can be rectified. You are paying to be properly trained and supervised and if that is not happenning then it needs to be corrected.

 

[DPTinFL]

I'm on my first clinical rotation doing acute care at a big hospital. Before the internship started, my school stressed the importance of direct supervision by the CI at all times. If your CI is not in the same room with you then it is not direct supervision. If you are transferring someone and they fall and break something while your CI is treating another patient in another room or chatting in the nurse station, then it it your CI's license on the line and you will probably fail your rotation. Talk to your CI first and discuss that you are not comfortable with the supervision provided as well as email your school's ACCE.

 

[darkangel77]

Thanks for the responses. My CI will always be in the gym when I am treating patients, though he does not help out (even if there are, say, 3 patients at a time, he will not voluntarily come and take one of them) unless specifically asked. From my observation, it seems like most of the other students with me on the rotation do all the treating, and we formulate treatment plans on our own (but we can ask our CIs for feedback), while the CIs are only there to answer questions. I have one classmate that is on my rotation with me (thankfully), and two others from a different school (one is on their last affil and the other on their second).

But yes my school does require that we complete an evaluation at the end of our affiliation, and unfortunately I cannot ask to be re-placed (I was already re-placed once...I was assigned to an outpatient clinic first, but I dislocated my patella the day before clinic started and was pulled out while I recovered and attended physical therapy). I am also at the last 8-week block available for this year.

 

[jesspt]

Sounds like you need to have a "come to Jesus" talk with your CI. I would also talk with your school's ACCE and let them know of the conditions that you've encountered during your first affiliation. I would also pick their (the ACCE's) brain about how to best have a productive talk with your CI in order to hopefully produce a change in their behavior. This talk will also come in handy if you have a difficult mid-affiliation CPI because the ACCE will already be aware of the situation.

In my opinion, the behavior of the CI's (if they can truly call themselves that) at this location sounds inexcusable. They are using you for free labor rather than instructing you in how to best apply the didactic information you have within your current clinical environment.