Clinical Observation and Documentation

When I was shadowing a hand therapist in undergrad, she would spend 15-20 minutes documenting notes after seeing each client and then at least an hour at the end of her day everyday documenting more notes. I remember asking her once why she spent so much time documenting and she told me it was beneficial for her in remembering who the client was, what their situation was, and what kind of activities were done on that day. I just thought it was for the purpose of her remembering ROM and client progress, but now learning about documentation first hand I realize it's so much more than that. Not only does clinical documentation provide observations by the OT, it also gives us a chance to justify our services (the why and the how) and its our opportunity to showcase our services and why we are important.

Like I said in the last post, I like having something laid out for me and organized. This is why I think I will enjoy goal writing and the SOAP note when I become a practitioner. Goal writing will help me keep myself organized when intervention planning for each of my clients, both short-term and long-term goals. It will also be a reminder of what my purpose as an OT is, to satisfy the client's goals wants and needs. I think the SOAP note method will also keep me organized in the manner of being able to locate things when I go back and look at my documentation. I'm excited to learn how to implement these things in a clinical setting.