During one of earlier my placements I came under scrutiny for my documentation in the integrated notes. I was a little confused as I was still using the SOAPIER format but I was just missing out the A and the P, as this tended to be just a rewritten list of the above assessment. The other physio’s had written even briefer entries tending to write only the most essential things and often taking up less than 4 lines ( I was taking up about ¾ of a page). I discussed this with the supervisors and agreed to write out full SOAPIERs for every patient to further my understanding of the patients problems, my entries were now well over a page.
During subsequent placements I managed to shorten the length to about ¾ for a new patient and about half a page for continual patients. I dropped the A and P and focussed on the other areas.
I was still writing more than most physios and it made me wonder if I was writing too much. I talked to a couple of physio’s about this and they had differing opinions. Some would say that it would always be better to write too much than not enough, while others would say that you should write the bare essentials as doctors, nurses etc often get annoyed at having such thick files for patients integrated notes.
This made me think and reflect on not only my own notes but what the purpose of writing integrated notes was. Surely we need to describe our assessment we have performed and the treatment we have carried out not only for legal reasons but to enable other health professionals to gain a greater understanding of just exactly what we are doing and have done with the patient. Giving a 4 line entry not only gives false impressions as to what we are doing with the patients but undermines our role as it portrays a simplistic and seemingly unnecessary treatment. This situation made me realise that we need to be thorough with our documentation to ensure our continued role in the health profession as well as to ensure the safety of the patient.
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2 comments:
Hey trav,
its a bit of a tricky situation, i have had this before aswell and i think it depends on the situation/area. Personally i think of the notes i prefer to read when i flick through the integrated notes and i prefer the shorter concise message. I think the main thing is to include all "relevant information" from your Ax and Rx and make it as concise as possible.
I have often been told by supervisors that doctors and nurses just like to be able to quickly skip through and see the current status of the patient. So if i am writing a very long entry then i will underline or highlight imp. points for the nursing staff with an asterix eg for mobility status. Or finish my SOIER format and write
Note: Nursing staff please use hoist to t/f or something at the end.
Good post Trav. I agree that this situation can be quite frustrating when different people say different things, very confusing! My position on notes is that there is nothing wrong with long, thorough notes (i write my notes that way) provided that you set it out so that doctors/nurses can find the info relevant to them quickly. I have also been told that they like brief notes (fair enough too), but as a physio following on from another physios treatment it can be difficult if thier notes don't have enough detail.
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