I started my 3rd year of DPT, my 2nd internship, and my 1st week of Acute Care! Oh and we were threatened by a hurricane, but it did not make landfall in Miami. It has been a whirlwind (sorry, hurricane pun, i had to)
Here are some things I have learned my first week of Acute Internship:
The documentation system
The EMR system in a hospital is a little more complicated than in an outpatient clinic. I actually love chart review. I love seeing all the patient info, and understanding all the pathologies, and then seeing how a patient presents when we go see them.
I learn how to do chart review: the key things we need to look for. It’s fun for me: it’s like a mystery where we’re putting together all the different parts and being diligent to look for anything important. Some important things we need to look for: is the patient under hospice care? If so, they would not normally receive PT. Does the patient have an acute fracture? If so, we need clearance to see the patient. Does the patient have orders for a brace? If so, we need to see if the hospital is providing it, or if they already have it. Has the patient gone from a regular room to ICU? If so, we need new orders.
I learn how to document. What to write for different patients, key words we need to include, how to rate patients in different areas, and how to sound like a PT, and not just some random person writing stuff lol.
In the acute setting, taking a patient history is different from an outpatient orthopedic history. Similar, but different. The key things we ask in an acute history is confirming A&O x4, their home setting (at home or in a facility, in a house or apartment, alone or with family), their PLOF (did they bathe/dress themselves independently, did they use a walker or cane), their pain level (are they currently experiencing any pain, if so where and for how long? If it’s a great deal of pain, we let the nurses know).
ETOH use or abuse is a more polite way of saying alcohol abuse. Lol I did not put that together.
Sjogren’s Syndrom is a disorder of the immune system identified by its 2 most common symptoms: dry eyes and dry mouth. It’s common with other immune system disorders like lupus or RA.
Near syncope just means someone feels like they’re near fainting. Pretty obvious but I also didn’t put this together.
A CT is usually done at admission and 24 hours later
Overall the first week of acute care is totally different from other settings, and nothing can truly prepare you for what it’s like, and especially for what that first max lift is like. Luckily, my CI is AMAZING and I am learning so much!!