My CI has photographic memory and was able to remember every patient I saw so she knew which note to check at the end of the day. Some days I would have 8-11 patients.
My classmate was able to see 11 patients, write his notes and be done with work at 2PM.
Every therapist, including my CI never had a notepad but can give me a full account of what we heard during the pt interview, can correct my notes and point out the details that I missed.
I had to write down everything the patient said so that I can write a detailed note when I got back to my desk.
Here is my cheat sheet.
*It was a derivative of a cheat sheet that another student shared with me. Thank you Ayesha!
- I like that I can write 4 evals on 1 sheet.
- It has all the key questions to get a full hx.
- I would write the admission date on the top right hand corner to see if the pt is oriented to time.
- Top 2 lines, I fill out from chart review so I remember who I am dealing with, his/her room #,
baseline BP and general dx/ precautions.
- And lastly, it folds in 4 so it fits perfectly in my white coat pocket and the palm of my hand so I
don't need to carry a clipboard.
Picture from I am Science Geek Blog.
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