Charting - how do you handle it?

[Yadeela]

I didn't want to hijack a thread, and I felt this topic is important enough for it's own thread.

I'm in my internship and they only give us 15 minutes between clients to change sheets, etc., so no time to chart then either. I have to do it at the end of the day, and for this newbie, it can be hard to remember *what* I noticed or did *when* and *on whom*!

Making those mental notes aloud as you're doing other things (going to wash your hands, changing the sheets, taking the laundry to the bin, etc) ~ yes, talking to yourself ~ will help to keep track of clients & issues. Perhaps a small recorder would help? or, does your cell phone have voice memo? You can let technology to the remembering, and simply play it back when you get to charting.

Those abbreviations and squiggles from the back of "Hands Heal" by Diane Thompson are huge time savers in doing SOAP notes.

Anybuddy else care to share charting strategies?

 

[Darin H]

The recorder is a great idea! I have seen quite a few doctors that do that, so why not us? It totally makes sense. I would not have remembered that without your sharing. Thanks.

 

[Meagan]

Honestly if I were afforded only 15 minutes btw clients, I would cut the hands-on time by 5-7 minutes. That's just not enough time for me to change sheets, recenter, grab a drink and a bite of protein, and chart effectively, and I've been doing this for 11 years. My charting doesn't take long, but it does take some time!

Also, I do the "S" part of charting, and a little of the "O" (what I see and test), right while I'm interviewing the client - saves time.

"O" using symbols on the body drawing if possible, and fill in text end-of-day as needed.

The "P" can probably be left for the end of the day, if it's ususally "M x 1 wk; cont ice and stretching as directed" or similar simple instructions.

Take good care of yourself on that schedule. Keep your sheets handy and grouped in sets; keep water and a protein snack right in the room if you can; take a sip of water when the client turns over, or do one quick simple stretch while client turns over. You will get through it!

 

[B.C.]

Good part is, I only have 11.5 hours to go!

We don't get the papers back to do any charting until after the client has checked out and filled in the evaluation form on the back (1/2 goes to the evaluation and 1/2 goes to charting. And we've been encouraged to chart, but not *too* much. They don't want details!) If I were to cut a client by 5 minutes, I'd get into trouble. They watch when the sessions begin and end.

I have HIGHLY encouraged my "non-math" dh to allow himself 30 minutes between clients. I actually had him a schedule set up from which to choose time slots for appointments, but he never used it! He gets weary easier when he only has 15 minutes between clients, and sometimes even less (he accidentally books them literally back to back). We're working on that one! That doesn't happen often though, and he is not so busy that he can't slide the next client back by five minutes if necessary. It really helps that he has a sink right in his room, and he keeps his dirty linens basket in there too, so he doesn't actually have to leave the room between clients.

I have been keeping a bottle of water (or two) and snacks in the room with me- that helps TONS. I also have told them that I don't want to do three back to back (with only the 15 minutes between) anymore. The last time I had to do that about killed me! I have changed my schedule to not even allow more than three sessions per day, and as I get there I can have them slip in a break of at least 30 minutes somewhere, so I won't overdo it. I took out my "in between" days off (I was originally going 2 days on one day off), so I am scheduled for 2-7 for the next 5 days. I *should* be able to get done by then! I can TASTE it now! LOL!

Denise, thanks for the suggestions. I can't take notes on my cell phone, but I do like the recorder idea. I might implement something of that nature when I get into "real" practice.