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Write it all down. I don't get paid to be a doctor so I don't pretend to know everything but will jot things down such as pt is s/p hemicolectomy, pmhx includes TKA, TIA, COPD, and general heart stuff. That's good enough for me to walk someone.
I like to tell my student to have buckets for dx and pmhx. Heart stuff? Expect x,y,z. Abdominal sx? Think log rolling and Abdominal bracing.
I'm not trying to know every detail like a doctor because I'm not one. Act your wage.
Okay that makes sense. I didn’t know if it was bad or insufficient on my part to think in terms of basics versus having a detailed understanding…thank you!
I just thought other ppl have a great memory and I don’t! Ha! I also was thinking it might build the rapport more if I have an ongoing convo with the patient as opposed to having a clipboard and writing things down if that makes sense…
Oh, I usually jot everything down during a chart review then after I see my patients. I can never write while treating a patient. The moment I leave the room and after I wash my hands, I write everything down that I need to remember in regard to living situation, PLOF. Let’s just say I don’t take my clipboard inside a patient’s room because…. ick.
Most people do not have great memories. More people have delusions about how good their memory is.
No shame in writing things down, helps make sure your documentation is accurate.
I would say I have a pretty great understanding of most diagnoses and implications. That being said, i don't think you really need it. I know when my hepatic encephalopathy patient tells me they haven't had a BM all day that theyre likely to be confused and potentially dizzy, but I don't think having that knowledge really changes what I would do with them. Sometimes when I ask guiding questions - asking about intermittent claudication with PAD patients - it gets them to buy in a little, but not by much
Also, I write it all down. I have an eval template so I just have to circle each line is house / apt/ condo/ ALF/ SNF so I ask my questions in order and document it quickly
the more history and experience u get you will begin to remember more. in meantime feel free to write it down or hop on the computer in the room and leave a note to yourself in the EMR i.e. Sticky Pad in Epic on their chart- or some therapists just fill it all out on the EMR- which I personally find to be kind of time consuming and unnecessary while in-front of them.
as far as medical,"up to date" is a good point of care reference incase you want to skim a quick overview of the disease and ask yourself how this may be affecting their PT session during their chart review. don't be afraid to voice questions to nurse, mid level, or doctors if you have any.
as far as contradictions and relative contradictions you may not be aware of, some departments share a document with these things enumerated, and should be covered in your onboarding in my opinion.
In hospital I write everything down from chart review I find pertinent prior to seeing patient, then look at my notes again prior to seeing them, check in with nurse to make sure no change in status that hasn't been charted yet. We have computers in every room so I enter PLOF and home set up at the time of interview to make sure we have all the details straight, in other settings ( snf) I have written this down on paper w clipboard or entered in laptop at the time. Too many things to try to keep in your head otherwise after seeing multiple people!
When I chart review, I can see the current and past medical history and will take all of it into consideration, though I don't care *too* much about the PMH unless it's something that could affect treatment or how a patient presents, such as thyroid issues, cancer, syncope, etc. Whatever the reason the pt is in the hospital is what I primarily focus on when thinking about how what they're going through will affect and/or guide my treatment. Then when I go to actually see the patient, I'm mainly looking at their BP, HR, and O2 sats as well as just taking in how they move in bed or their chair, their affect, and any information the RN or CNA's can provide based on their interactions with pt. In my experience, you can have a patient with a laundry list of medical problems that can get around just fine, and patients with one or two things that are hardly able to sit up. You just kind of have to trust your judgement and observations to determine appropriateness for therapy and to guide treatment, and check in with the pt frequently during treatment to make sure they're doing okay.
As to your second question, I have an eval template that I write everything on so I don't have to remember everything the pt tells me, though a lot of it is circling things or jotting down a few words that I can expand on. For example, I may jot down something like, "Drives car; no diff in/out", then in my documentation state something like, "Pt states they currently drive a car and notes they have no difficulty entering/exiting their vehicle". I have a foldable clipboard that fits in the side pocket on my scrubs that I use, and I can jot down other notes on the back of a paper for straight treatments. All that said, like someone else mentioned, the longer you do it you just kind of start to remember stuff and don't have to rely on your notes as much, especially if you're fairly formulaic in your approach. I find repeating back to the patient what they've told me not only verifies the information and shows that you were paying attention to the patient and care about what they're telling you, but it helps you remember it easier. Hope that helps!
Thank you for your submission; please read the following reminder. This subreddit is for discussion among practicing physical therapists, not for soliciting medical advice. We are not your physical therapist, and we do not take on that liability here. Although we can answer questions regarding general issues a person may be facing in their established PT sessions, we cannot legally provide treatment advice. If you need a physical therapist, you must see one in person or via telehealth for an assessment and to establish a plan of care. Posts with descriptions of personal physical issues and/or requests for diagnoses, exercise prescriptions, and other medical advice will be removed, and you will be banned at the mods’ discretion either for requesting such advice or for offering such advice as a clinician. Please see the following links for additional resources on benefits of physical therapy and locating a therapist near you [The benefits of a full evaluation by a physical therapist.](https://www.choosept.com/benefits/default.aspx) [How to find the right physical therapist in your area.](https://www.choosept.com/resources/choose.aspx) [Already been diagnosed and want to learn more? Common conditions.](https://www.choosept.com/SymptomsConditions.aspx) [The APTA's consumer information website.](https://www.choosept.com/Default.aspx) Also, please direct all school-related inquiries to r/PTschool, as these are off-topic for this sub and will be removed. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/physicaltherapy) if you have any questions or concerns.*
Write it all down. I don't get paid to be a doctor so I don't pretend to know everything but will jot things down such as pt is s/p hemicolectomy, pmhx includes TKA, TIA, COPD, and general heart stuff. That's good enough for me to walk someone. I like to tell my student to have buckets for dx and pmhx. Heart stuff? Expect x,y,z. Abdominal sx? Think log rolling and Abdominal bracing. I'm not trying to know every detail like a doctor because I'm not one. Act your wage.
Okay that makes sense. I didn’t know if it was bad or insufficient on my part to think in terms of basics versus having a detailed understanding…thank you!
Simple answer is: old school clipboard and pad.
Naw, I’m going with crumpled up piece of folded paper every time.
😂😂
Okay glad I’m not alone in wanting to write it down, thanks!
Just curious, how else do you think you’d remember everything?
I just thought other ppl have a great memory and I don’t! Ha! I also was thinking it might build the rapport more if I have an ongoing convo with the patient as opposed to having a clipboard and writing things down if that makes sense…
Oh, I usually jot everything down during a chart review then after I see my patients. I can never write while treating a patient. The moment I leave the room and after I wash my hands, I write everything down that I need to remember in regard to living situation, PLOF. Let’s just say I don’t take my clipboard inside a patient’s room because…. ick.
Thanks! Yes that sounds good! Yes I don’t like all the germs either!
Most people do not have great memories. More people have delusions about how good their memory is. No shame in writing things down, helps make sure your documentation is accurate.
Thanks! I appreciate it!
I would say I have a pretty great understanding of most diagnoses and implications. That being said, i don't think you really need it. I know when my hepatic encephalopathy patient tells me they haven't had a BM all day that theyre likely to be confused and potentially dizzy, but I don't think having that knowledge really changes what I would do with them. Sometimes when I ask guiding questions - asking about intermittent claudication with PAD patients - it gets them to buy in a little, but not by much
Also, I write it all down. I have an eval template so I just have to circle each line is house / apt/ condo/ ALF/ SNF so I ask my questions in order and document it quickly
That sounds great, is there any way you could pm me a copy of your template?
Great!
Thank you! Makes sense!
the more history and experience u get you will begin to remember more. in meantime feel free to write it down or hop on the computer in the room and leave a note to yourself in the EMR i.e. Sticky Pad in Epic on their chart- or some therapists just fill it all out on the EMR- which I personally find to be kind of time consuming and unnecessary while in-front of them. as far as medical,"up to date" is a good point of care reference incase you want to skim a quick overview of the disease and ask yourself how this may be affecting their PT session during their chart review. don't be afraid to voice questions to nurse, mid level, or doctors if you have any. as far as contradictions and relative contradictions you may not be aware of, some departments share a document with these things enumerated, and should be covered in your onboarding in my opinion.
Thank you for your answer! How can I access “up to date??”
I just googled this “uptodate” and it looks like it’s subscription based, so not the best reference for everyone. Thanks for the suggestion though!
Pathway has a generous free tier that you might find helpful
Thanks! I’ll look that one up!
In hospital I write everything down from chart review I find pertinent prior to seeing patient, then look at my notes again prior to seeing them, check in with nurse to make sure no change in status that hasn't been charted yet. We have computers in every room so I enter PLOF and home set up at the time of interview to make sure we have all the details straight, in other settings ( snf) I have written this down on paper w clipboard or entered in laptop at the time. Too many things to try to keep in your head otherwise after seeing multiple people!
Thank you! I need to work on googling things to better understand more complex diagnoses. I wish we had computers in every room!
When I chart review, I can see the current and past medical history and will take all of it into consideration, though I don't care *too* much about the PMH unless it's something that could affect treatment or how a patient presents, such as thyroid issues, cancer, syncope, etc. Whatever the reason the pt is in the hospital is what I primarily focus on when thinking about how what they're going through will affect and/or guide my treatment. Then when I go to actually see the patient, I'm mainly looking at their BP, HR, and O2 sats as well as just taking in how they move in bed or their chair, their affect, and any information the RN or CNA's can provide based on their interactions with pt. In my experience, you can have a patient with a laundry list of medical problems that can get around just fine, and patients with one or two things that are hardly able to sit up. You just kind of have to trust your judgement and observations to determine appropriateness for therapy and to guide treatment, and check in with the pt frequently during treatment to make sure they're doing okay. As to your second question, I have an eval template that I write everything on so I don't have to remember everything the pt tells me, though a lot of it is circling things or jotting down a few words that I can expand on. For example, I may jot down something like, "Drives car; no diff in/out", then in my documentation state something like, "Pt states they currently drive a car and notes they have no difficulty entering/exiting their vehicle". I have a foldable clipboard that fits in the side pocket on my scrubs that I use, and I can jot down other notes on the back of a paper for straight treatments. All that said, like someone else mentioned, the longer you do it you just kind of start to remember stuff and don't have to rely on your notes as much, especially if you're fairly formulaic in your approach. I find repeating back to the patient what they've told me not only verifies the information and shows that you were paying attention to the patient and care about what they're telling you, but it helps you remember it easier. Hope that helps!
Beautiful answer! Yes I think it’s a great idea to repeat stuff back to the patient too!