Tag: charting

10 May 2015

Help! I can't get my charts done!

My last question is, were you ever bogged down in your medical records? I end up spending all my free time completing them and never have time any more to keep up on journals, your website, etc.  maybe there is a section on the website you can direct me to.

L.

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As for the medical records... I find that I have to do them almost immediately after the patient is gone - or I am left with 10 - 15 charts to do at the end of the day when my brain is fried!  Sometimes I will stop what I'm doing in the treatment, give the dog a break and write some stuff down.  The owners are usually okay b/c I tell that that if I don't write it down now that I'll forget by the end of the day... and the dog sometimes needs a break anyways.  And I confess that sometimes to just get away and a bit of time to myself, I'll take a chart to the bathroom and do it in there between patients!  (Too much information???)

Lastly, you might be surprised at how basic my charting is.  In my case, it's just me (or occasionally one of the other therapists) that needs to see my charts... and the rule of thumb in physio is that you assess and treat what you find that day anyways.  So looking at the chart to see what was done last just provides a 'guideline' for the treatment you may do that day.  For example:  

S: Going up and down stairs now, Still won't jump into car

O/E: Decreased tenderness iliopsoas.  Pelvis level, mild tenderness L7 with transverse pressures

Rx: Laser 10 J/cm2, 50% multiple sites to iliopsoas & L/S, PEMF 15Hz x 30min, Mobs L7, Myofascial release iliopsoas, Home Ex: Feet up stretch forward for cookie.

Simplify!  When I have an intern that's shadowing for their rehab certification, I tell them to tell me which patients they want to copy the notes for and that I will do an extra detailed job of the notes... otherwise, what I wrote above is about all that I do.

Beyond that... we also build in buffer time between patients.  We know we're going to run late.  So while we have the appointments set up to be 1/2 hr appts, we schedule them ever 40 minutes.  That way we don't get behind, and there's a chance we'll get charts done.

Hope that helps!!

Laurie

 

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11 Jun 2017

Do you use SOAP? Not me! No SOAP for me!

No SOAP

I hate SOAP. I don’t use SOAP.

I use my own charting categories, and I’ll suggest you might like to do the same!

Did I make you raise your eyebrows at the title?  Just a little?  Likely not!  Ah, disappointing…

 

Okay, so when we have interns come to our clinic, they are asked to provide an example of a SOAP note.  I always tell them, we don’t use traditional SOAP notes.  I don’t think they fit an outpatient practice.  Subjective and objective make sense.  Subjective is what the owner tells us happened, how things are going, what they’ve been doing, observing, etc.  Objective is what you find on your clinical evaluation of the dog (gait & movement analysis, what’s painful on palpation or ROM, or movement testing, what’s tight, atrophied, and your objective measures, etc.)  Sensible stuff!  But beyond that, I would like to make suggestions / alterations to the A & P parts of SOAP.

 

Classically, (and I dug out an old text book from 1990 to get this right… a whole text book on SOAP notes!!!), the A is for Assessment, where you would fill out a summarized list of the major issues from the S & O sections.  Okay, so this is likely dandy as part of your initial assessment, but it’s a pain in the butt to do with every charting input.  In our initial assessments, we use PT impression or PT Diagnosis.  That’s where I’d write out my thoughts 1) Suspect OA left shoulder and maybe put some bullets below:  Pain on end ROM flex / ext; Reduced end ROM flex; Off-loading LF leg.  And we’ll often have multiple findings i.e. 2) Rib and T/S dysfunctions, 3) abdominal motor control and timing deficit.  I could add in my goals etc. as well (in my initial assessment primarily).  But let me get back to a follow up treatment note.

 

In my follow up notes, I’ll use Subjective & Objective, and if there is something new that has come up or a change in my thinking of what’s going on (or a subtle nuance to what I think is going on), I’ll add in “I” for Impression.  Then I like to go with Rx (meaning treatment).  If you prefer you could use Tx for treatment.  Here I write what I did during the treatment THAT DAY.  I include therapy type, dosage, body part treated, etc.  Laser 2J/cm2 Superpulsed, Mobilizations T/S (dorsal glides and Transverse Pressures) – Grades 3 - 4.  (P.S.  I hate charting ‘amounts’ of manual therapy… it’s a ‘feel’ sort of a thing.  But that’s another topic.)  

 

If the dog had a fabulous response to my therapy (or in the case of a neuro dog) and I was to describe how the animal was after the treatment (or how he was during the session), then I’ll add a category for ‘Outcome’.  I think this is important.

 

Plan for me, means 1) What I plan to do next time, 2) What I’ve prescribed as homework, 3) When I want to see the patient again, 4) Anything else I PLAN to do (i.e. send note to referring doctor, email client exercise sheet, etc.)

 

All in all, I don’t use SOAP.  I use SOIRxOP!  And I feel ‘clean’ just the same!  If you’ve been struggling with SOAP, I hope this might work for you as well!

 

Cheers!  Laurie

 

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