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Note Taking in a Hospital Setting

By Fiona Breytenbach on 17 September, 2019

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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.


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