Are case notes handwritten or recorded in digital format at your facility Emma? If the latter's the case then there are several compensatory software options that may assist text production, depending on the specific manifestation of the symptoms of your dyslexia.
One well known program used extensively in the UK is Text Help Read and Write. The Gold option has integrated scanning functionality (allows paper documents to be scanned in then read out by synthetic speech). Several other useful features too. I have also had several clients managing text production well using Speech Recognition software eg Dragon Naturally Speaking. The Preferred versions and above allow voice notes (made into a digital voice recorder) to be transcribed by the software into digital text - and the text to speech/read back button can allow the user to proofread the result. There are obviously personal ,organizational, technical and environmental issue to consider with any intervention of this type. David Harraway Occupational Therapist ComTEC Yooralla Society of Victoria > I may be misunderstanding the question, but I am thinking that Emma is asking > for help with SOAP notes as they relate to her dyslexia, not what they are and > how to do them in general. Am I on the right track Emma? > > Pat Ellison > > At 09:24 PM 7/13/2006, you wrote: > >> Hello Emma >> First of all - What setting do you work in? Are you required to use the SOAP >> format for your chart notes? >> >> We use a similar but simpler format DARP >> Data - eliminates the need to separate 'subjective' and 'objective'. I find >> this helpful. Using SOAP I was always realising that I had left out >> something the client had told me after I was into my own observations. Of >> course it is necessary to use phrases like 'Mr. B. stated' to clarify where >> the information came from or use quotation marks. Also it is easier to use >> when data comes from several different sources. (Are the daughter's >> contributions S or O?) >> Actions - what you did. This allows you to record what you did 'on the spot' >> rather than writing a plan and developing another note to record stuff >> already done. >> Response - from the client. Quotes are good here. What you want to record is >> whether your action was acceptable to the client and what difference, if >> any, it made. >> Plan - what you are going to do next to fulfill the treatment plan you >> developed after your first assessment. >> If your note is to record a brief contact, one or two episodes, be sure to >> state an occupational performance goal in your plan. >> >> Whichever format you use - I find it helpful to jot down my plan, preferably >> before I leave the client, so I have a written record of what I said I was >> going to do. Then as I begin to write the chart note my plan cues me to what >> happened and why I had decided to do that rather than trying to keep the >> plan in my head while I write all the rest down. Hope this helps. >> Joan Riches >> >> >> >>> -----Original Message----- >>> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf >>> >> Of >> >>> Emma Cole >>> Sent: Sunday, July 09, 2006 9:25 AM >>> To: [email protected] >>> Subject: [OTlist] Some help. >>> >>> Hi, >>> I am a OT in uk and have difficulty with my note writing due to my >>> >> dyslexia. >> >>> I was wondering if anybody have information on SOAP notes and information >>> >> on >> >>> writing them as it is getting me down at work. >>> Many thanks >>> >>> emma >>> >>> >>> >>> -- >>> Unsubscribe? >>> [EMAIL PROTECTED] >>> >>> Change options? >>> www.otnow.com/mailman/options/otlist_otnow.com >>> >>> Archive? >>> www.mail-archive.com/[email protected] >>> >>> Help? >>> [EMAIL PROTECTED] >>> >>> -- >>> No virus found in this incoming message. >>> Checked by AVG Free Edition. >>> Version: 7.1.394 / Virus Database: 268.9.10/383 - Release Date: 7/7/2006 >>> >>> >> -- >> No virus found in this outgoing message. >> Checked by AVG Free Edition. >> Version: 7.1.394 / Virus Database: 268.10.0/388 - Release Date: 7/13/2006 >> >> >> >> -- >> Unsubscribe? >> [EMAIL PROTECTED] >> >> Change options? >> www.otnow.com/mailman/options/otlist_otnow.com >> >> Archive? >> www.mail-archive.com/[email protected] >> >> Help? >> [EMAIL PROTECTED] >> > > > > -- Unsubscribe? [EMAIL PROTECTED] Change options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected] Help? [EMAIL PROTECTED]
