Writing notes in the hospital

Your evaluation and notes in the hospital setting is not too different from the notes you write in the skilled nursing setting or home health. One of the most tricky things will be learning to use the hospital documentation system. Not all, but most hospitals use EPIC which isn’t typically used in other OT settings.

Likely there will be a procedural flow of how a therapist takes notes that will involve inputting sections of information at a time. Usually for evaluations it’ll involve inputting the one liner from the doctor, precautions, the prior level of function, ADL and mobility levels currently, an assessment, and the discharge recommendations. The treatment note will likely be similar but omitting sections such as the one liner and prior level of function. As with most things, it will depend on the hospital. Let’s talk about each section of the note.

One liner

Sometimes epic inputs it automatically in the note. I’ve also worked in places where you need to copy and paste it in.

Prior level of function

This will involve interviewing the patient: -“Do you live on your own?” If not, “who lives with you? Will they be able to help you full time?” If it’s an elderly couple I’ll also ask whether their partner is comfortable physically assisting. -”Do you have stairs to enter the house?” “Do you have steps inside the house?” You can also ask about the presence of railings on R or L. -”Prior to coming the hospital were you able to get dressed, bathe, and toilet without help?” If not, you will need to gain some clarity with each ADL. -”Do you have any medical equipment at home? Such as walkers, canes, commodes, shower chairs and grab bars?” “Is your shower a walk in shower or bathtub?”

ADL and mobility levels

It will likely be a dropdown box where you will input assist levels for mobility and the ADLs the patient performed during your session.

Assessment

Each therapist has their own note taking style. This is how I like to structure my notes:

1. Quick synopsis of why the patient was admitted and sometimes how the doctors are treating it.

Those one liners can be long! I like to get down to the basics. That sometimes includes what I learned from the patient during my session.

“Pt was admitted after fall resulting in R femur fracture s/p IMN.” “Pt with 4-5 admissions to the hospital in the past 5 weeks admitted for AMS 2/2 UTI currently on antibiotics.” “Pt with recent admission for lymphedema 8/20 discharged 8/24, readmitted for B LE edema and shortness of breath 2/2 noncompliance with bumex medications because of environmental barrier in the shelter.”

They all give important information to the next therapist. The first patient is someone that needs particular attention to orthostatic blood pressure readings, balance, caregiver training, and falls prevention in addition to the orthopedic injury. The second person is likely not doing well because they have been in and out of the hospital and may be considering a palliative or hospice discussion. Therapy will be more focused on achieving the person’s goals than aggressively pushing mobility. The third person needs OT to focus on medication management and how to remove barriers or provide supports for the patient to safely discharge.

Side note: Most therapists do not do the quick synopsis but I personally do because it gets me conditioned to think analytically during my chart review. The chart review is one of the most challenging aspects of transitioning to the hospital. Post will soon be following concerning that.

2. Quick synopsis of patients prior level and how they’re doing now.

“Pt was independent at baseline, coaching softball and riding his bike. Currently below level of function requiring grossly Min A with mobility and ADLs with FWW.” “Pt had a full time caregiver and was bedbound at baseline but was able to feed herself. Currently requiring Mod A for feeding due to upper extremity weakness.” “Pt was modified independent with mobility with a FWW but needing assist for LB ADLs. Currently Total A due to ROM limitations and pain from swelling.”

3. What you did during the session and assist levels.

“ Requires mod A for donning socks in supine. Pt sat up from bed, Min A to support R LE. Pt stood up with FWW, CGA. Attempted weightshift but unable due to 7/10 pain in R LE despite premedication before therapy. Able to engage in stand step transfer to chair, CGA.

Put it all together and you have your note. Every therapist does it differently. You’ll likely adopt the technique of the person training you and can branch out from there and develop your own style. The important thing is that you’re demonstrating skilled therapy, supporting the need for continuing therapy, and backing up your discharge recommendation.