Documentation

 I had the opportunity to practice my documentation skills on my last Level I Fieldwork rotation. Dr. Woods was actually my clinical instructor on my placement. Each night we had to write a SOAP note of what we observed that day. I am attaching a screenshot of my SOAP note that I wrote and her feedback on it. 

I mainly got corrections/comments in my objective and assessment sections. Dr. Woods pointed out that some of the things I would say in the objective should be assessment. She said to think of how I can state what I observed directly that led me to the conclusion regarding level of activity. For future SOAP notes, I kept that in mind when writing the objective section. I know that I just need to write about what I saw and what happened during the session. For my assessment section, she stated that I was on the right tract, but again I confused one statement where I should have stated it in the objective section. I know now that assessment provides evidence and explanation of what you saw during the treatment session and what can improve during future sessions. I really enjoyed her providing positive feedback for my Plan section. It is encouraging to know that I am doing something right. By the end of my rotation, I had improved a lot from my first SOAP note. I feel more confident in what to write in each section and I appreciate the feedback Dr. Woods gave me throughout my two weeks of SOAP notes.