Soap Note Made Easy (Pt, OT, Speech, and Nurses- documentation)
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- Опубликовано: 10 сен 2024
- Per request Famous Physical Therapists Bob Schrupp and Brad Heineck demonstrate their note writing techniques use the SOAP format.
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These gentlemen should get rewards. They both have no idea how helpful their videos are; the informations they share are very very helpful for a student like me. Thank you!!!!
Thanks Bob & Brad great way of explaining the basics of writing SOAPs
Last time I was at my ophthalmologist's office, I happened to catch a glimpse of my file on the computer. The first line was "Michelle is a very pleasant..." and it made me feel so good about myself. It honestly made my day and maybe my week. I came here to learn how to write a good SOAP note and left a better SOAP note writer who apparently isn't uniquely pleasant!
Paperwork is the worst part of the job. Just like when you go to the bathroom. ;). But, it didn't happen if it's not documented. So, it's extremely important. I seldom document who the patient is. This is a good reminder. Thanks for all your great videos.
Great! Can you do one for students on the complete "Patient Medical History" that you would do with a real patient to show all the steps for my physio students?
Amazing video!! Thank you for sharing!!!
You guys are awesome. Thanks for sharing!
Sir, what documentation in the medical record you can do if the patient refused to have a treatment with the Physiotherapist Assistant? plz help.
Thanks for clear and concise information
Good reminder for PT, could you make video about, what is Physiotherapy, methods PT, why PT calls the basis of rehabilitation and etc. Thank you .
wow. been looking for this. thanks
Hi Sir. I know this is out topic but In patients with stroke, is CIMT better than prismatic adaptation in allowing visual attention to the neglected limb? Thanks:)
I was really having a hard time getting my Soap note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍
Hi,so are SOAP notes written in your 'initial' patient evaluation or just for other co workers to know? Or do you have pre printed forms to fill in for assessments?
Thanks in advance!
Can you direct me on creating a good Narrative note? Thank you
Why did New Jersey get all the toxic waste and California all the lawyers?
--- New Jersey got to pick first.
I really appreciate all your videos. In a short message it's hard to explain the why but I am a graduate of PTA school 9 years out and am just now about to take my exam. I need all the the refresher help I can get. I was a good student but 9 years is a long time ago it seems. Are there any videos of yours you would particularly recommend for me? (I've already watched a a lot) Also are there any other you tube channels that you know of that might be of some assistance to me? Also my current job is with children I recommended your video about swinging children by their arms to my boss after an incident at work. It was helpful to the situation. It helped some who didn't have the medical background understand what had happened.
I really have been doing test prep other places. I've more been using your videos to help solidify things in my brain. Having not worked in the field in a long time. They are good reminders. I always look up the anatomy and technical terms after if I can't remember thanks for the reply.
Clarification : obviously I put their name on the note. I also add if they have any complaints (pain, fatigue, etc) or if they have had any medication changes and I record their vital sings including O2. I work in Home Healthcare, so slightly different than outpatient.
PTA and my pay has been about the same as working in an LTC/rehab facility, which is more than a hospital or outpatient facility. But, the flexibility in hours and the fact that I only see 5 or 6 patients a day really makes home health my favorite.
Kyle Dempsey I'm in Columbus Ohio and our cost of living is probably a little lower than Atlanta, so that per visit rate sounds about right. There are a few things to consider when thinking about your pay versus your actual hours working. First thing is your drive time between patients. How long will it take to drive between patients homes? Also, paperwork. How long will it take to complete notes? (electronic documentation takes less time, IMO). Other considerations are car expenses. Will the employer pay mileage? Most do not. Miles are deductible are taxes, though.
Kyle Dempsey As far as the number of visits per week, that can vary. Keep in mind that as a PTA we cannot do the evaluation and then just keep the patient m. We rely on the PT to give us the patient. So, as long as the PT is busy, the PTA will be busy too. Often home health PTAs will sign up with local LTC facilities to do prn work to supplement income when the patient load is low.
Kyle Dempsey In general I would recommend getting a couple years of experience working with geriatric patients first before doing home health. You will have very little supervision when you do home health, so get some good experience first
Kyle Dempsey I typically work about 7 hours for 5 days a week and then about every other Saturday just to make up for a couple of missed visits. Sometimes you can get a new patient on Wednesday or Thursday and they need to be seen once that week or they need to change an appointment for some reason, so I always keep my Saturday mornings available just in case
any advice for confirming gender/sex without making the client uncomfortable?
I just ask..."What gender do you identify with?" or "With what gender do you identify?"
I feel if you ask the question directly and professionally it may reduce the chance of an awkward situation.
Look at them
Alfonso Vitalli yah I'm in a really arbitrary/bad advanced injury class and had to figure this out. I just gave them paperwork to fill out.
Seriously??? These medical records can be accessed by patients - they belong to them. They end up in court, etc. So you are going to put whether they are pleasant, unpleasant, fat, etc? No.
Mostly post soviet countries, don't give home exercises)))
Gumby! Gotta be adaptable!
First sentence should always be obtaining pt consent! #lawsuit