Clinical Observation & Documentation


During class today, we learned about Clinical Observation and Documentation. It made me very thankful for my past experiences that allowed me to get some practice in both subjects. During high school, I took a lot of health science courses and we spoke a lot about what to do if an error is made during documentation, so I learned to be in the habit of that. During my undergraduate career, I majored in Therapeutic Recreation (which is very similar to OT). During our classes, we learned about the importance of objective language. I had an internship working with individuals with special needs, and my coordinator forced us to document every client we worked with. While I hated it at the time, I now realize how beneficial this was in preparing me for being an OT. At the end of my internship, my coordinator had me go back and compare the notes I was writing then with the notes I had written at the beginning of my time there. I was terrible when I started! It was honestly embarrassing to read what I had written just several months before. My coordinator used it as a teaching moment to show me how much practicing helps with being a clear and concise documenter. I’m thankful for all my experiences that exposed me to skills I will need in my future career.

Comments

Post a Comment

Popular posts from this blog

Steve Gleason

Steve Gleason was a safety for the New Orleans Saints. At 34 years old he started feeling a twitch in his arms, shoulders, and back. Symptoms progressively worsened, and a year later he was diagnosed with ALS. After his diagnosis, he founded the organization "Team Gleason" which advocates for individuals diagnosed with ALS. He also began recording a video journal of his life that is now a documentary called "Gleason". Steve Gleason is married, and after his diagnosis he and his wife decided to have a child together. I thought this was so interesting and very telling of their love for one another! In 2013, Steve was given the opportunity to work with Microsoft in developing a wheelchair that could be controlled with eye gaze, and he became the first person with one of these chairs! Eventually, Steve was put on a trach and feeding tube, so he is now completely dependent on this technology. Through all of the struggles that ALS can cause, Steve continues to work hard i...
Read more

Neuro Note 3: Tourette Does the Talking

I don't know a lot about Tourette's Syndrome, but I have always been intrigued so I chose to watch the TEDx Talk Tourette Does the Talking by Thomas White. I would highly recommend for everyone to watch this video. Thomas is a college student living with Tourette's Syndrome. As he is introducing himself he says, "I stand before you today, hoping to lay bare the inter-workings of a mind that attempts to remain robust, despite an unrelenting neurological assault". Thomas does a wonderful job of showing his robust mind, as well as the neurological assault he is faced with, making a clear distinction between himself and his Tourette's. This is a very raw look at a day in the life of someone with this type of Tourette's Syndrome. White, T. (2014, January 21). Tourette Does the Talking: Thomas White [video file]. Retrieved from: https://www.youtube.com/watch?v=0szLOMIt9SQ
Read more

BIG progress

The case study on Robert was so interesting. He is an 88 year old man with Parkinson's Disease, and was having a lot of trouble with motions to be able to perform ADLs such as laying down for bed or sitting to watch TV. It was really important for him to be able to go out to eat with his wife. The intervention approach was the LSVT BIG. It is a very intensive program, mostly for individuals with PD. Therapy sessions start out 4 times a week, and the client is taught how to do the program at home, with one month check ups. The program must be continued at home 4 times a week for the most success. We got to watch videos of the client before he started the program, going from sit to stand position and sitting to supine position. We then watched videos of him at his one month check up, and the progress was incredible! I was so amazed at how much he improved in such a short amount of time. The LSVT BIG is something everyone that works with geriatrics should be certified in.
Read more