Week 3 - wednesday

I have been working particularly hard on developing my soapier writing skills. At the commencement of the second week i decided it was a major goal of mine to achieve by the end of this prac and i will be very happy if i can write excellent legible patient notes. Today i completed soapier notes for a patient i assessed this morning. I am beginning to find it easier to find descriptive words that correctly define the patients subjective feedback and general observation. It is becoming more obvious to me what information is important to include and the information that can be left out of patient notes. My supervisor has been helping me develop my soapier skills and gives me excellent feedback on every entry i put down. She is particularly keen on laying out your work sequentially and neatly that follows your steps though tout the interaction with the patient. The layout of patient interaction is particularly important and should be considered before approaching the patient in particular the equipment that may be required and the plan of attack (i.e what may be assessed in sitting or supine). In my notes today i had difficulty with describing auscultation and what i heard in the lungs. i discussed this with my tutor which was beneficial. Formulating a plan with priorities is another skill i am beginning to develop. For most patients on my ward it is mobility that is preventing discharge but it is important to look at the whole person and clinically reason why mobility is decreased and what goals can be established to get this patient back to normal.
I am beginning to feel more confident with my patient notes and clinical reasoning. Overall today was an enjoyable day and i look forwd to developing my soapier skills on the remainder of this prac.