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Can somebody help me find a useful and efficient way in patient documentation (progress notes, etc..) In nurses, some hospitals in our country have used checklist type of documentation. Is there such a format for us physios who have a hard time finishing documentation due to high bulk of patients treated in a day?
It would be best if you could sent me a template of your forms as a guide for us in developing one....thanks
We are taught the SOTAP method...
Subjective
This includes the subjective assessment, any thing you have read about the patient in the patient notes, anything the nurses have told you etc...
Objective
Observations on how they were doing the tasks- gait, STS, bed mobility, outcome measures, etc...
Treatment
What treatment you used and what assistance, aids were required
eg. walking ~20m 1xA (assistance), walking frame
Analysis
Your reasoning behind what you observed. Such as " pt requiring support during walking due to reduced R lower limb strength"
Plan
What you plan to do in the upcoming sessions....
this is important for the next physio in case you are away...