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Raising the Bar in Rehab

Documentation

Published January 20, 2009 4:03 PM by Lisa Catenacci
Well, here is my greatest internal frustration thus far at my clinical- documenting.  For the sake of argument, let's assume that my evaluation and treatment sessions go by flawlessly (although, obviously, I have many areas to improve upon).  Then, I have as much time as I need to write up the note- as a student, this is a wonderful gift, but few clinicians can say they have unlimited time to write their notes.

The frustrating part is I know what needs to go into the note.  I know the important thing.  When my CI adds corrections, I think to myself, "I KNOW THAT, why didn't I put it in there?"

I think part of the issue is the computer documentation system is not set up like my brain.  I don't think in terms of tabbed browsing, with boxes to check off for different details.  When I attempt to keep the assessment concise, so the next therapist doesn't have to read my novel to get a good understanding of how well the patient is progressing, I inevitably forget something I should have included. 

I'd rather write too much in the note, than not enough, but even when I've attempted that route, my CI will edit out the unnecessary details, reminding me to keep the note short and to the point. 

My dream documentation system- I would write out a play-by-play, narrated by John Madden, of everything that happened in the session.  Then Oprah would wrap it up with an assessment of how the patient progresses, how far they are from their baseline of functioning, and the plan for the next session. 

Hopefully next week will be better. 

1 comments

Right out of school I had the pleasure of splitting myself between two teams:  ortho and neuro.  So as a new grad I had three bosses:  the big boss, the ortho boss and the neuro boss.  What an ideal world!  

If I hadn't already learned it as a student with different CIs, I learned it at this first job:  No two people think the same or write the same or require the same information.  Even when they aren't your CI, or boss, every PT writes notes a little differently.  And even during their best weeks, seasoned PTs forget details.

Though they may not admit it, your CIs are learning as much from your documentation as you are.  That is one reason clinicians volunteer to be CIs, because it helps keep their skills sharp--reminding them of what is and isn't important.  

In your quest to become an excellent clinician, the most important skill is to never quit learning.  So far, it sounds like you are off to a great start!

Janey Goude January 22, 2009 2:12 PM

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