The best advice any experienced clinician will give you is to keep good clinical notes. In school, you will learn both the AETN - Assessment, Education, Treatment, and Next visit note style. You will also learn SOAP notes: Subjective, Objective, Assessment, and Prognosis notes. Both designs provide the busy clinician with a framework for including all of the most significant and important information for each patient you treat and the services you provide. It is important to document what you do - but also why you do it. Having a framework will keep you organized when you are busy or running behind. Organized notes help you keep track of your appointment, focus on important information, and easily review previous notes. In this episode, we will review both of the frameworks for clinical notes to help students learn the basics of the structure of a clinical note, how to write them, and why they are important.
As I say.... "Those who know will grow."