Note Taking in a Hospital Setting
United Kingdom · CPD points & talks · Psychologists
It can be so useful to have a structure when writing notes after meeting and assessing a patient. This is a way to ensure that you cover all the relevant assessments and that the notes can be useful to you and to other professionals at a later stage. Fiona Breytenbach gives us some ideas about how an occupational therapist in a hospital setting can systematically assess a patient and make clear and concise notes. This structure can be used by any medical professional assessing a patient, and facilitates multidisciplinary collaboration.
Fiona refers to the SOAP note-taking method, which includes Subjective and Objective observations, Assessment and Plan.
The 'Subjective' component includes the patient's own reports on their current presentation, while the 'Objective' component includes any immediate observations the therapist makes upon meeting the patient.
Fiona then describes the 'Assessment' component, including her full assessment of relevant aspects, such as perception, limb function, mood, motivation, and level of awareness. She then notes an initial treatment 'Plan', including treatment interventions the patient may be eligible for based on initial assessment. This is helpful should another therapist review these notes, allowing the other practitioner to pick up or implement treatment suggestions.
Not only does Fiona offer a useful note-taking structure; she also offers a window of insight into her systematic assessment process when working with patients.
If you're interested in going on a meaningful professional development journey in the area of neuroanatomy, watch Fiona's fantastic and thorough Building Brains talks here.
-Leanne
CalabashCalabash ArticlesCalabash PartnersCalabash ContributorsCalabash SpeakersCalabash TalksCalabash Sign upCalabash Sign inTalk · Stuttering: An overview of assessment & treatmentPersonality CPD talksArticle · Shape Shifters and the Vascular LabyrinthHIV CPD talksPrivacy PolicyCalabash · South AfricaCalabash Articles · South AfricaCalabash Partners · South AfricaCalabash Contributors · South AfricaCalabash Speakers · South AfricaCalabash Talks · South AfricaCalabash Sign up · South AfricaCalabash Sign in · South AfricaTalk · Sensory & Emotional Regulation 4: Picky eating · South AfricaChildren, Teens & Families CPD talks · South AfricaArticle · Case Study: Managing tinnitus in my practice · South AfricaPsychosis CPD talks · South AfricaAbout Partners · South AfricaCalabash · AustraliaCalabash Articles · AustraliaCalabash Partners · AustraliaCalabash Contributors · AustraliaCalabash Speakers · AustraliaCalabash Talks · AustraliaCalabash Sign up · AustraliaCalabash Sign in · AustraliaTalk · Cultivating a Neuro-affirming Practice: Sensory Processing Consideration In Therapy Setting (Part 2) · AustraliaCouples CPD talks · AustraliaArticle · How my therapist missed my diagnosis: a patient’s experience of PND · AustraliaDepression CPD talks · AustraliaPrivacy Policy · AustraliaCalabash · New ZealandCalabash Articles · New ZealandCalabash Partners · New ZealandCalabash Contributors · New ZealandCalabash Speakers · New ZealandCalabash Talks · New ZealandCalabash Sign up · New ZealandCalabash Sign in · New ZealandTalk · Working with Posttraumatic Stress: Current & contextual considerations · New ZealandClinical Issues CPD talks · New ZealandArticle · A GP's perspective on Mental Health Referrals · New ZealandFreud CPD talks · New ZealandAbout Contributors · New ZealandCalabash · United KingdomCalabash Articles · United KingdomCalabash Partners · United KingdomCalabash Contributors · United KingdomCalabash Speakers · United KingdomCalabash Talks · United KingdomCalabash Sign up · United KingdomCalabash Sign in · United KingdomTalk · Understanding and Managing Central Auditory Processing Disorder · United KingdomAustralian Counselling Association CPD talks · United KingdomArticle · Tidbits on Treating the Dizzy Patient · United KingdomWriting CPD talks · United KingdomPrivacy Policy · United KingdomCalabash · United StatesCalabash Articles · United StatesCalabash Partners · United StatesCalabash Contributors · United StatesCalabash Speakers · United StatesCalabash Talks · United StatesCalabash Sign up · United StatesCalabash Sign in · United StatesTalk · Neuropsychological Assessment · United StatesClinical Issues CPD talks · United StatesArticle · Common Medications for Mood Stabilization · United StatesLearning Difficulties CPD talks · United StatesTerms of Use · United StatesCalabash · CanadaCalabash Articles · CanadaCalabash Partners · CanadaCalabash Contributors · CanadaCalabash Speakers · CanadaCalabash Talks · CanadaCalabash Sign up · CanadaCalabash Sign in · CanadaTalk · On Villains and Victims in Couple Attachments · CanadaAllied Health Professionals CPD talks · CanadaArticle · Decolonising Psychology? · CanadaSupervision CPD talks · CanadaTerms of Use · Canada
Psychologist in Sydney