the written Word

over the last three placements, I have often though about what we - and other health professionals - write.

Most of what I have been thinking of is the utility (usefulness) of our writing for those who read it. Legibility is a big issue, of course, but there is also the key content. I notice some physios make themselves much more effective through a few key habits:

• writing 'E/' items that that give a quick picture of where pt. is instead of just showing that their 'I/' was effective e.g. instead of "I/ STM HS || increased KE" one could write "I/ STM HS || decreased QL 12 degrees to 3" - the second one tells how much effect the Rx had, where the pt should be if the Rx had a lasting effect / gives basis for deciding whether HEP has maintained gains, etc.)
• writing 'R/' items that point the way for next time. When we finish an Rx session and are writing up the notes, this is the time when we best understand how to continue next time. E.g. instead of writing "R/ progress HEP" or "continue Rx, we can write items like: "Check Gl Med. strength, add Gl Max X.s", we will save ourselves & others the time to needed to plough through the O/, I/ & E/ to hopefully remember / figure out where pt is at.

And of course, there is legibility. Obviously, we are wasting time & ink if our writing is not legible. But people still do it - often in situations where poor communication could endanger the pt or prevent other health professionals from optimizing the efficacy of their Rx. I haven't figured out how to respond to crappy writing... one idea is to track the writer down and ask them 'hey, what is this you have written here'... but usually I find I don't have the time and just skip over what might be important info... frustrating. Anyone have ideas?