@tienguyen thanks for coming up to eat buffet.

Mondays. Fundays. Learning. #blessed Do I see myself doing it? Well I need to see it through first. #tgim

Former Aggies running into each other at Csus. Good seeing you. @hanichiyomi

Wave Runners. Chasing a dream. You are a part of it.

Study break

Internship OP

  • sAt least every other week:

–      Describe event

–      Reflect on your thinking about it now

–      How did you FEEL about what happened?

–      What effect might your reflecting have on your learning and/or future practice

Week 1

Monday 6/2/14  Seascape Physical Therapy and Fitness

Start:  8:00am

Finished:  5:00 pm

Today I came in nervous, scared, and excited.  Traffic was not bad going to PT but coming home was a little slow.  Overall wonderful first day, I got to put my hands on patients, follow them through treatment, and observe evaluations.  The bad part of the day is that there are 2 cancellations which is normal in physical therapy but it became time to catch up on paperwork and documentation.

My CI is currently Jim Tucker PT,OCS owner and founder of Seascape PT and Fitness Center.  PT and Fitness Center are in different suites of the same plaza.  This set up is a good way and business implication to keep patients adhering to HEP and keep them in the loop. 

The things I saw today with patients that came to physical therapy were mainly middle and elderly aged adults with pathological conditions ranging from LBP (old age, other comorbidities and past THA,TKA), post-op RC(SAD{subacromial debridement/DCE),  spinal fusion, post-op knee surgery, and muscular strain(M. gastroc.).  Much treatment related to hands on soft tissue mobilization, range of motion (PROM and AAROM), and pt. education. 

I had difficulty time managing with patients and having a sense of how much time I was taking to treat.  I had problems reading my CIs notes and being concise, knowing when differential diagnosis was needed in a red flag type of situation.  I felt unease because it seem sometimes my CI would bill for something that he may have partially done for example billing an extra unit of manual therapy 30 minutes instead of 15 minutes (actually performed) or when an evaluation and treatment was less than an hour but billed for an hour amount of time. 

I have many goals the first week which consists of

1)being able to read the charts quicker (get pertinent information regard to that day of treatment) and follow up with treatment,

2) write a SOAP note(and get it signed),

3) being able to complete an evaluation by my second week,

4) understand how to bill and code,

5) become better at increasing ROM through manual therapy (assessment (finding landmarks, and reassessment) (jnt mobilization and different PNF stretches). 

6) Evaluation:  writing general goals and plan of care

7)  orientation to intake, scheduling, and general pt. flow.

8)under standing admin requirements relative to MD dx, rx, medicare and other insurances

9)understand the pt. chart and be able to greet, obtain subject, basic objective information

With my knowledge and background information, one of my goals is to learn more about the pathologies behind it and learning to progress a pt.  Keep learning the research behind these things and read up on orthopedic PT. 

Tuesday 6/3/2014  10:00am-6:00pm

Today was difficult for me because I felt like I did not do anything PT related.  I was slated to come in at 10:00am.  My CI brought me around to give me an orientation of the health, wellness, and fitness side of his operation.  I got the opportunity to see how his fitness side of the business is operated and how patients then progress from the PT to fitness center program.  I met with other health professionals such as personal trainer and nurses.  Jim and I had the chance to go over certain clients and their goals as far as weight loss, comorbidity management/consideration if they are starting a wellness program. 

After Jim and I discussed our goals for each other in a meeting and then he had me go write some goals for myself and read about shoulder pathologies.  I used myself as a patient to help me learn as he gave me some reading resources from his OCS module/manual to read on pathology, management, and treatments.  Towards the end of the day, I went back to the physical therapy end and started to work with patients that had LBP w/ radiating symptoms, cervical pathology, and encephalitis. 

The other PT, Laura Dunn, had me start pulling charts and reviewing them and guided me with treatment on a patient with low back pain.  She supervised me as I did my subjective.  I had difficulty conducting a subjective as I did not know what aimed questions to ask.  She told me to ask about an activity limitation and to see if it improved due to treatment and HEP.  At first, I was lost on where and what to put my focus on when greeting a patient and doing their subjective.  What was difficult for me was then trying to reproduce their symptoms in an objective 2nd visit.  I performed PAIVMS but wish I had more feedback on finding a  hypomobile segment on the L/s.  Laura taught me to compare the height of my thumbs on the facets to see if anything is rotated, then apply Graded pressure to see if any reproduced my patients symptoms.  I felt relieved and excited as I felt that began a good relationship of teaching/learning from another CI in the clinic.  She told then after “thank you for applying yourself” and also ask questions because she knew I was more up to date with research and articles.  Reflecting on this event and day will help me in the future by being able to ask my CI and other PTs about their clinical reasoning and manual skills. 

Wednesday 6/4/2014 8:30am-6:00pm

Today was different from yesterday.  I got the opportunity to have more hands on manaual therapy on patients that were coming in who has suffered different injuries and coming in with different histories.  My CI supervised me through much of the treatments today and taught me how to perform some soft tissue mobilization on calf strains, ankle replacement (STAR), total knee, and total hip. 

One difficult thing today was me teaching a patient how to do exercises especially lumbar stabilization exercises.  I was too focused on the intricate detail which made it difficult for the patient to comprehend all the information that I was giving her.  My CI helped me by making movements such as bridging simple to teach with simple commands.  He told me to have them do the exercise first before teaching them then correcting that they did wrong and reinforcing what they did correctly.  At that time I felt incompetent because I made a simple task so difficult.    This has helped me to gain confidence teaching patients in the future by not making a simple exercise so difficult with jargon and detailed instruction.

I had the chance to write SOAPs after each treatment for a couple of patients and discussed the patients’ progress and modified their goals for next treatment.  This was difficult for me because I still have difficulty trying to hone in on a specific goal or movement to assess on.  My goal next time to have a preassessment, treatment, and post assessment.  This will help me identify what treatment is helping the patient and which treatment has no effect/effect.  It was good to work with patient from different backgrounds and comorbidities.  For example I got to work with a patient with an ankle replacement but had history of incomplete SCI that I would have never notice if I did not ask or read the chart. 

Tomorrow I get a chance to work with another PT.  she is CPI and I would love to get clinical practice as far as treatment goes in conjunction with her CPI certification. 

Thursday 6/5/14 8:30am-6:00pm

Today I got to work with my other CI who is a female PT.  She has a background in pilates.  I got to work with many interesting patients today ranging from lumbar fracture due to osteroportic changes caused by medications from prostate cancer, low back pain, deconditioned pts, shoulder impingement, cervical disc/peripheral nerve pathology, achilles tendonitis, achillies tendon rupture repair, and TKA. 

I got the chance to do treatment consisting of teaching therapeutic exercises and progress a patient through their HEP.  I did some soft tissue mobilization with joint mobilizations on a patellofemoral joint which has a TKA.  I did some STM to decrease swelling in conjunction with posterior glides to increase flexion.  Pt. had 108 degrees of knee flexion and goal was to get to 120 degrees.  After treatment I got my pt. knee flexion to 115. 

I also did my first supervised evaluation of a pt. c/o medial knee pain with LBP.  I got to clear the hip and knee joints. Then performed a valgus test and mc murray test.  On another patient I got the chance to assess a shoulder for ROM and performed some shoulder flexion stretches overhead to increase lat length. 

The most difficult thing during the day was evaluating a patients knee because I had difficult recalling tests for patellofemoral pain, and lacked the hand skills to perform proper special tests.  Next time I should have been prepared but it was my CI who gave me short notice.  I felt like I was not ready and not comfortable with the situation.  In the future, I need to speak up and say that I am not confortable with the patient and diagnostic impression.  I think I need to be supervised more and walked through an evaluation to accurate assess a patient.  This gives me a baseline of where I am at.  My goal is to complete a full evaluation with a POC written down signed by my CI by the 4th week. 

Friday 6/6/2014 8:00am-1:00pm

Today there were many appointments book in the morning and I got out early because my CI had a personal training and nutritional appointment with a client that was private.  I worked with patients that had LBP, TKR, and conditioning for a THR. 

I got to follow up and write SOAP notes that each patient.  With the pt. w/ LBP, my treatment was mdoalities(heat and E stim), STM,and ther ex(lumbar stabilization). I had 3 total knee replacements which one was ahead of schedule in regards to ROM in knee flex/ext, another pt. gain ROM initially but lagged in progress, and the last was not making progress due to the environment at home and their lack of motivation.  This was a good experience to see 3 different types of pts. and see how much a home environment, support, and personality/motivation plays in the prognosis of a total knee replacement.  

One difficult thing was experiencing how my CI told me that a certain patient will not have a good prognosis.  I know not all patients will reach their goals but I never experienced this first hand.  I always believe if a pt. was motivated and had some resources that they would have a chance to return to PLA.  In this instance seeing different pts. with TKR, it was a reality and seeing my CI have a lack of hope for a pt. surprised me and caught me off guard.  I felt shocked but also I understood where he was coming from by seeing pts. who were not motivated made it hard to help them with treatment.  This will affect me in the future because it will help me see if I am making progress and working with different pts. will help me practice with a goal of d/c if they reached their goal and not keep patients who aren’t progressing.  Also it makes me think that I need to have a big tool box of different treatments because every patient might not respond to just one type of treatment. 

Week 2

Monday 6/9/2014 8:00am-5:00pm

I realized that this physical therapy clinical is a 1 man show.  My CI is the owner, and only PT there.  The practice can get busy at times and overwhelming.  I am starting to feel more comfortable with the workload as far as seeing pts throughout the day.  The day goes by very fast and I am not sure if it is a good thing or bad thing. 

I saw the same pts. as last week and have been building rapport with them.  This has help with me building my confidence to implement treatment and progress exercises.  Today was special because I got to see patients with different pathologies again.  They ranged from s/p lat. Mall. Fx(MOI:hypereversion), shoulder impingement, herniated disk(pedicatric), d/c LBP, obesity preventing her from having a TKA, and plantar fascinated with LBP/sciatica/TOS. 

Hands on skills today and most recently were doing joint mobilizations on lower cervical/upper thoracic PA, PA/AP of the TC joint(pt. s/p L mall. Fx) w/ cast disease(stiffness and tenderness(midfoot).   I also got the opportunity to watch/participate in 2 new evaluations.  1 was the pt. s/p L lat. Mall. Fx., and another pt. w/ plantar fasciitis. I got more hands on skills with measuring ROM with different joints, discussing SOAPs with my CI, and more variety of joint mobilizations. 

I have noticed progress with myself with writing SOAP notes but need to work on my penmanship and grammar.    

One new event today was running my first patient intake with a patient w/ plantar fasciitis.  I had difficulty guiding my pt. through the subjective because she would also talk about her other pathologies.  It felt like as if I were doing 3 subjective/objective exams on a person’s MOI.  Thinking on about it now, I should have took more control and became more direct to the problem I wanted to address which was the PF.  I was glad my CI was able to watch me do my pt. intake, perform/teach pt. thera ex: finding subtalar neutral, strengthening intrinsic muscles, developing HEP, management of pain, developing a POC and making goals.  The part I didn’t like was not having control of the pt. intake because I am bad at managing my time and asking questions that only relate to the pt. dx.  I felt incompetent at that moment in time.  After that was a great learning experience as my CI helped me with the objective.  Reflecting on this will help me have urgency in time as well as asking the right questions.  It will also help me see how to deal with pts. with other disease and comorbidities. 

Tuesday 6/10/14 8:00am-7:00pm

I am beginning to feel more comfortable working with patients and explaining them some exercises.  I worked with pts. w/ LBP, TKA, L/S wedge fx, balance impairments, s/p chemo treatment, and left hip HO.  Today I had less time with hands on manual therapy but more with pt. education and instruction.  I also prescribed a home exercise program for a pt. with a TKA and assess their knee flexion ROM.  Overall I feel as if I am getting better with treatment by assessing and reassessing a patient’s limitation. I also observed an evaluation of a pt. that s/p excision of an accessory bone and replacement of the posterior tibialis tendon.  

I learned with older patients it takes a little more time for them to process information and directions.   I am currently trying to write a SOAP note for every patient I see and discuss 25% of them with my CI.  I got the opportunity to take some subjective information for 25-50% of the patients coming in today.  I helped developed some balance exercises that were looked over by my CI for 1 pt.  measured ROM of the knee, balance measures, OM(6 minute walk, SLS,).  Overall, today I felt as if I had more freedom to do many therapeautic exercise but that came at a penalty.

With increased freedom, I had a difficult time managing my time with patients because they would be out in PT later than 1 hr worth of treatment which billing had to be accounted for.  Some patients enjoy spending more time, while others do not.   For example, one patient with my time management was terrible because it took me 2 hours to get through one patient.  One of my other difficult patients was one with a wedge fracture who was mod-max assist with transfers and bed mobility.  It was difficult for me to change positions to perform some certain exercises.  I did a mod-max assist from supine to sitting edgeOB.  This event was difficult for me and I was afraid I was going to hurt my patient.  There was a lack of confidence because I had a hard time transferring patients in general. I felt afraid because I felt as if I was by myself.  I needed to communicate more with my CI who was also in the same room but working with another patient.  Next time I run into a situation like this, I need to speak up with my CI and ask for help.  Although my patient I worked with did not get hurt, this is not always guaranteed that my patient will be fine and also myself.  Reflecting back I need to make safe decisions for my patient sake and myself.  Overall, I need to learn precautions to certain treatment and patients for example when not to do electrical stimulation. 

Wednesday 8:00am-5:00pm

I got to experience many things today that will help me develop into a better physical therapist in the future.  I think one goal is to d/c 25% of my patients that I see with CI supervision.  I believe the goal of a physical therapist is to help patients recover and get back to PLA or better function and this can not be done without d/c.  I reencountered the same patients in the past week and observed an evaluation/patient intake with a dx of herniated cervical disc but signs and symptoms showed something else.  I learned from this that sometimes the dx from an MD and MRI are accurate but it might be more important to see how it affects the patient. 

I have been getting more hands on experience for example performing joint mobilizations on a pt. w/ an ankle replacement.  I also walked through and developed a home exercise program for a patient w/ shoulder impingement and was able to discharge him.  In general, I am more comfortable with assessment but still need work on having more experience with an evaluation and a progress note for d/c. 

One problem I ran into today was being efficient and time management.  I had to ask questions to my patient about their progress.  In addition I had to finish their therapeutic exercise/add new exercises before d/c.  I was thinking about what is the best way to save time so I felt I cut the therapeutic exercise short and taught her more ROM techniques.  For some reason it is hard for me to verbalize some of the things I am teach my patients that I have less supervision on.  Although I had more free, I believe I felt more comfortable with my CI walking me through certain things and questions for the patient note and discharge.  In future references, I need to have confidence in myself and speak up so my patients can comprehend what I am conveying. 

Thursday 6/13/14 8:00am-7:00pm

Today was a very busy day with our 2 person team with 12 patients.  Documentation can be hard to catch up especially in a small gym/clinic.  There are no PT aides or PT assistants.  I treated patients with LBP, neck pain, TKA, lumbar fracture, and PD.  Today, my CI taught me techniques that I did not learn in school such as specific Mulligan techniques:  Sustained Natural Apophyseal Glides (SNAGS) and Mobilization with Movement (MWM) for the treatment of musculoskeletal injuries.  I had a chance to assess, treat, and reassess, and treat a patient today with neck pain.  My treatment included therapeutic exercise and manual therapy consisting of glides to increase neck rotation. 

I was uncomfortable because I had never managed 2 patients at the same time.  One patient where I had to verbally cue her to perform her therapeutic exercise and another patient where I had to perform joint mobilizations.  There were 2 feelings going through my mind.  The first was my lack of confidence doing joint mobilizations and the second was panic when I had to manage the other patient with their exercise program.  Although these emotions were going through my mind, I knew I had to show confidence.  The way the gym was set up I was able to verbally cue and make eye contact with my patient doing her therapeutic exercise program while also performing cervical glides with a patient in the room.  Looking back, I believe juggling two patients was difficult and I should have asked my CI for some assistance.  My fear of asking someone for help or even having questions for my CI currently might be slowing down my clinical education.  Although this fear is present at times, I have been getting more comfortable asking questions and asking for more responsibilities as well.  Reflecting back on building my confidence and managing 2 patients at the same time will benefit me in the future where I can learn through my CI and be able to work with more patients.  Having more patients will help me prioritize my time and have balance juggling patients and documentation. 

Friday 6/13/2014 8:00-1:00pm

Today was a short day because my CI has short days on Fridays.  We have patients for half a day.  My new goal is to become efficient at doing evaluations and choosing tests that accurately show a patients impairment.  Everything else is going well.  I feel I am getting more opportunities to work with patients. 

Only problem was that I need to keep control of evaluations and be confident and concise with my verbal cues.

A problem I had today was again time management with teaching a pt. his HEP and writing a progress note to send to the insurances/MD to show that my patient is indeed in need of PT.  I felt nervous about my writing and I have trouble communication to other professions on a documentation status.  I felt some anxiety writing because I knew this is important for my patient to get more treatment.  I believe this is crucial for future practice as I am my patients’ keeper and advocate.


Week 3

Monday 6/16/14 8:00am-5:00pm

Coming in today I felt nausea and sickness.  I had to still be at my best.  I had a good mixture of pt. education, special tests, 2 evaluations, progress notes, SOAP notes, and keeping the gym in good shape.  Overall I still feel that I am a novice at many things and need to improve my skills. One thing today that stood out for me was having a well planned out pt. intake and evaluation.  I think preparation is key but having the repetition to get better at ascertaining information.’

One event today that I did not feel comfortable with was my evaluation because I felt lost as far as asking certain questions to get information.  I felt I was waiting and relying on my CI to ask the next question or if I did ask a question it was not drilling into the information as much.  I feel that I am not preparing as much as I should have.  I feel that I am doing too many things and not getting good at one to two things.  I need to discuss my goals with my CI and how to get to my goals in order to become a good PT in the future.  In the future it would be great to work with other PTs and also have autonomy. 

Tuesday 6/17/14 8:00am-5:00pm

I came into my internship feeling much better than yesterday.  I feel that I am becoming better at gathering my subjective, following up on certain impairments and functional limitations that are presented in the patients’ charts(25%).  Also I am feeling more comfortable about adding and progressive patients.  For example, a patient with  L Hip Arthritis had trouble with balance, she was already doing single leg stands with abduction on the other leg.  So I decided to add over variations to increase her balance by adding single leg stands with different directions such as marching and extension.  These became kitchen sink exercises. 

Overall I do feel that I am beginning to take more of a lead in new evaluations, writing SOAPs, and progress notes almost up to 25-30%. 

Today I also worked with a patient who was having headaches and low back pain.  He had pain with walking when he first came in.  As his pain subsided over couple treatments, I was able to have him do a 6 min walk test outside.  I feel I am incorporating more OM that are proven to detect change.  

Two challenges today was a patient with a wedge fx of L/S.  He is still mod assist +1 on transfers and bed mobility.  I still question why he is able to go to outpatient.  My challenge was giving him exercises that he could accomplish and have minimal pain.  This pt. had me critically think about what position is best to not increase pain.   My CI and I did exercises in sitting, standing, and supine positions.  Overall he still had pain leaving therapy.  I learned from him that patients will not have a decrease in pain right after therapy but I feel that I aim too.  The second challenge was having an evaluation at the end of the where my CI and I were running behind on time and had to be out by 5:00.  We had 45 minutes for an evaluation and treatment.  I felt rushed and the pt. in my standards was not getting the care that that person deserves because of time management.  I felt like it was my fault and I should have managed my time efficiently.  This goes to my practice in the future; I should have buffer time or schedule a less complicated patient before an evaluation vice versa. 

Wednesday 6/19/2014 8:00am-5:00pm

Today was a mixture of working with patients, evaluations, documentations, cancellations, and no shows.  One thing I need to work on is having an assessment, treatment, and then reassessment.  Another thing I need to work on is during treatment such as joint mobilization being able to have the strength and endurance to sustain 10-15 minutes of joint mobilization and increasing range of motion.  I have been feeling better at giving and progressing simple therapeutic exercise for patients with hip and knee OA.  I am comfortable with working with patients through given exercises but I have trouble with explaining them to patients due to lack of confidence and voice projection.  My goals are to perform more evaluations without the help of my CI, write more SOAP notes, work on my manual skills and special tests. 

Today, I had an informal meeting with my CI.  My CI gave me some constructive criticism and told me to have more confidence and speak louder and clearer. 

1)       I will be able to speak clearer to my patients when instructing as measured by how many time my patient ask me to repeat myself.

2)      I will be able to conduct an evaluation, write a POC, administer HEP all within 60 minutes. 

3)      I will be able to manage my time by review patients charts before they come in and be able to work with them through their course of treatment for 50% of the time.  

4)      I will be able to implement an outcome measure for each new patient that I eval 25% of the time. 

My challenging moment today was talking to my CI.  I feel sometimes I am nervous and scared to speak with my CI for reasons I do not understand.  He is a really good CI but I wish there was more structure and variety of patients I can use special tests on.  I new challenge is to finish my doctorate project, and make a questionnaire that will show if patients that are transition from the PT side of the clinic to the fitness side are benefiting from it and are satisfied.  Friday will be my test on managing patients that a piled in a short amount of time and blocks. 

Thursday 6/19/14 8:00am-6:00pm

Today there were not any evaluations and some cancellations.  I learned some new techniques for muscle release and stretching.  It is called ART which is Active Release Technique by Micheal Leary.  My CI is certified and it costs about 2000-3000 to be certified.  This is expensive just like graston but it is a helpful manual treatment that I got exposed to today working with a cervical HNP.  I also got to practice my PAIVMs on cervical neck.  I practiced my teaching and exercise skills for therapeutic exercise and work on my patients home exercise program.  I now know how important it is to communicate clearly with my patient which I am having trouble with.  This was brought out with by my CI yesterday.  I taught that teaching someone therapeutic exercises correctly will off in the long run as they are an important tool and way of treatment to see if your patient can replicate/demonstrate in practice.  Retention of the HEP is important and can empower a pt.  Another problem is that I need to work on upper cervical special tests and got the chance to practice with my CI today.  Reflecting back on today, I learned that there are many techniques to treat certain muscles and different tools to help self stretch which can be easily produced.  Tomorrow I have an early morning that will be packed with patients for about 5 hours.  This will give me practice and test me with my time management and patient handling.  My goal tomorrow is do write SOAPS for all the patients I interact with tomorrow which will be about 50%. 

Friday 6/20/2014 8:00am-1:00pm

Fridays are usually short but packed with almost the same amount of patients on a regular day.  Patients are overlapped and everything is keep tight with time and patient management.  I was able to write about 3-4 patient notes today that write then signed by my CI.  Reflecting back on today, I feel very challenged still as far as managing patients but I am getting better.  I was able to work with a patient and have then be guided through their exercise program.  I am able to manage about 1.0-1.5 per hour with supervision and help.  I am getting more freedom and trust from my CI to work with patients alone while my CI is in the other room with the door open and able to supervise me verbally via vision of the mirror in the gym.  One of the biggest challenges for myself is speaking up or asking a question while my CI is working with another patient.  I find it difficult to know when exactly to ask or asking in a way where I don’t know interrupt my CI. 

Week 4

Monday 6/23/14 8:00am-5:00pm

Today was one of those days where many patients are cancelling or rescheduling.  Also it was a day where patients that usually work with one therapist are now being schedule on another therapist’s schedule.  This is happening because one of the other therapists at the clinic is quitting.  I am feeling that I am getting better at know patients’ names , dx, and treatment/POC without looking at their charts for about ¼ of the pts.  I think I met my goal as far as being able to read someones’ chart and walking them through their treatment which is mainly ther. ex. and manual therapy.  A difficult challenge today was feeling that I am not doing enough as far as giving a patient ‘enough’ exercises.  For example a complex patient I had today who took a week off of PT, came in, and I had him on the bike and performing dips.  He has PD, L/s fx @ L4, and history of cx.  He amb with a FWW and min assist now with his transfers to seat but his pain is slowing him down from PT.  It was difficult for me to call it a day because at times I feel more is not enough.  I realized sometimes less is more with certain patients.  This affects my future practice and knowing when what and how much dosage a person can take to be beneficial.    

Tuesday 6/24/14 8:00am-5:00pm

Again today there were many cancelations at the end due to July 4 holiday coming up.  I received for hands on manual therapy training today with patients with Hip pathology such as HO and OA.  I performed some distraction, lateral glide, inferior glide to increase hip flexion ROM for ADLs such as tieing shoes.  I was able to write a couple soap notes for some of the patients and talk about the through the process of a SOAP with my CI.  We spent the cancellation time to write notes, and discuss insurances and how they play a role if a patient will get another prescription or have to wait.   Ultimately, the #of visits has a huge role on how progress and POC is going to be determined.  I got to exam someone who had shoulder and neck pain that had some peripherlizing bilateral numbness in the finger but patient has 5/5 strength, and full AROM.  Although treatment has been centralizing her sx, I still feel some of the pain could be referred from a visceral organ such as (i.e. liver).  My challenge today was patient management and also how to recover from cancellations.  I felt lost but need to practice writing progress notes and ask questions related to patients initial evaluations.  I think it is important to have good measureable goals so it makes it easier to follow up with a progress note and to see if therapy is helping the patient in a clinical meaningful way. 

Wednesday 6/25/14 8:00am-5:30pm

Today was a better and smoother day.  I got to document 50% of the patients on schedule with SOAP notes.  I notice I am getting better at documenting because my CI doesn’t question me and signs after.  Today I noticed that I am able to document and guide a patient through an home exercise program. 

I had a good amount of manual therapy and therapeutic exercise teaching.  I got to experience my CI teach me and a patient agility ladder specific with a patient who had balance problems. 

My challenged today was having energy to carry my voice and project throughout the day.  I felt my communication skills got silent at the end of the day because I been thinking more and listening more to my CI and his instruction.  I need to become an active listener and voice my opinion.  I felt like I need to be equal to all patients as far as communication and this will affect me in my practice. 

Thursday 6/26/2014 8:00am-5:00pm

I feel that my note writing is become consistent everyday and that I am getting be at sifting information with a daily note.  I feel much more confident with my patient management of non complex patients. Total number of patients today was about ¾ of the usual case load.  This was nice for me to focus on writing progress notes and also discharging 2 patients.  I wrote about 75% of the daily progress notes for the patient and had the chance to learn more about mulligan and thoracic extension exercises to facilitate postural ROM.  I think the difficult things are still communication with patients which can always become better.  I need to find ways to start with a certain number for verbal cues then take away verbal cues.  At times the private practice could get slow and my CI has other obligations such as the fitness portion of his business.  I find it difficult to speak to my CI sometimes on topics that relate to PT and I need to address this issue as soon as possible. 

Friday 6/27/14  8:00am-11:00am

Today was a short day because my CI and the rest of the staff are participating in a golf tournament.   Today we had 3 patients come in, 1 was lack of mobility related to tennis, 1 Achilles tendon strain, and 1 polymyalgia knees.  There was 2 patients that actually came on time.  And one patient we thought was a no show but actually came an hr later than schedule.  When this happens we usually spend more time working with those we came on time and then work on the patient who was late.  Today was a challenge because we were expecting to leave on time and relatively had other things schedule.  But my CI loves to give everyone the equal amount and fair treatment and attention to keep patient retention.  I felt that this is how it should be managed and handled.  I felt obligated because I wanted to work with this patient and saw he could be making progress.  In the future, I think there should be a better system of communication to follow up with patients who are no shows or those who come late to PT.  I know there are many factors we can not control but at least try to control the factors and variables that we should. 

Week 5

Monday 8:00am-5:30pm 6/29/2014

Today was a busy day with many patients that were booked in an overlap fashion.  I had 3 things that I thought I was given more lead on as far as a SPT.  I got to lead with an evaluation, write a majority of the progress notes, and patient management.  Today we had a total of 11 patients which 2 were new evals, 2 were cash paying patients, and the rest had used their insurances.  My evaluation I did not have any confidence in as far as the objective part, my subjective I would give it a B-/B.  This is because I was not direct with my questions with my organization.  Then after I had to attend to another patient with their program.  With my evaluation I need to become organized and accurate with my objective, subjective, then knowing what to give my patients.  My CI gave me the challenge throughout the day of managing 2 patients at the simultaneously that were 15 minutes apart.  I think I did well managing two patients in the gym making sure one does the bike and the other will do an exercise with more supervision.  Things I did well communication and organization but the issue I need to improve on is always to project my voice. 

The part of PT I am getting better is writing soap notes with confidence because I am able to write then after I treat a patient and also write while I am treating a patient with verbal cues. 

Overall today I felt as if I am becoming better with documentation, a subjective, and patient management.  This will help me in the future because I know I will have to work with multiple patients and be better with management. 

Tuesday 8:00am-6:30pm

Today, PT started out terrible because we booked in 2 patients who were discharged a week ago which then gave us 2 hour openings which could have been filled.  This was great for the patient who had their appointment at 8:00am.  My CI and I worked on our patient as I had the chance to show my CI joint mobilization of the L hip with lateral distraction, long axis distraction, and inferior glide at EROM flexion.  All of these were trying to increase flexion ROM.  My CI gave me instruction 50 percent of the time and also showed me some manual stretching of abduction, hip flexion, and extension.  I am beginning to write SOAPs independently about 50% of the time.  After I got the chance to observe a patient with chronic low backpain that had a large psychological component.  My CI showed me how to manage a patient without touch the patient through verbal cues.  One of my challenges today was managing a patients who seem to do alittle extra and go over extra time in PT which then slows and backs up other patients.  I feel as if I am interrupting a patient and being rude to them by forcing them to “hurry up” and leave.  Another situation was during joint mobilizations of the ankle, I took too long working on PA glides and not enough of AP glides.  Although I am getting better, per my CI, I need to work on my time management and thinking ahead to be able to finish patients on time in an hour. 

Wednesday 7/2/14 8:00am-6:00pm

Today was a non hands on day because my CI had the day off where he had duties at the fitness center of his business/practice.  I had the chance to work and give verbal and tactile cues for an Essentials class.  An Essentials class consists of past patients from the PT side of the business who come over to the fitness side and take a class gear towards their pathology and ailment in a general sense.  It incorporates balance, strength, cardiovascular, etc. challenges.  The challenge for me was know when to give feedback and knowing when to step in to give feedback with a confident voice.  It was nice to feel like I was wanted as far the people who were in the class.  They seemed to enjoy my presence and my expertise.  The rest of the day I met up with my CI to develop my goals and to work on a survey that will help boost more patients who are discharged to come to the fitness center to be part of the essentials class, try other classes, and/or perform their HEP.  I realized running a PT practice by yourself is difficult let alone doing it with a fitness center.  PT is a profession and also a business.  Tomorrow will be at least a 10 hour day before the July 4th holiday.  I hope there aren’t many cancellations tomorrow.  I am currently working on a survey as my “inservice”.  I will approach as if It was my research project and collect data and outcome measures. 

Thursday 7/3/14 8:00am-6:00pm

Today I went in to PT with a long day with 13 patients.  Today I got to hold an evaluation with as little as 25% supervision, I was able to document, give an home exercise program, and document/fax to billing and insurance for one whole patient.  The rest of the day, I documented almost 75% of the patients that I saw.  I saw about 50% of the patients today which were about 6-7 and was able to help them through treatment and therapeutic exercise.  My weakness still is dosing a patient with exercise.  Making sure it is not detrimental but beneficial for them.  The challenge was getting documentation done before I left home.  I felt pressed on time because I know in the future I have to balance time between PT, documentation, family time, and my own time.  Sometimes it will be dipping more into one or the other but eventually I know I have to be good at all of them. 

Week 6

Monday 7/7/14 8:00am-5:00pm

Today was an average day about ~9 patients.  We had 2 evaluations today which I had difficulty with the evaluation part and being able to communicate the questions I had for them.  One patient was a patient with cervical, elbow and wrist pathology.  I did not know where the source of it was and patient had a history of RC and frozen shoulder so I had to be cautious while evaluating them.  I had difficulty being organized again and I think it has to deal with being able to work with 3 different types of joints and now knowing where then to treat.  My CI told me working at the neck will help with the symptoms because it could be related to double crush type syndrome.  The other patient was a post op but my challenge with her was having the confidence to ask the right questions for the right answers.  This patient is seeking the best care possible from surgery and I had difficulty with controlling the evaluation especially the subjective then know my limits to give them treatment after.  My goal is to stay on track during evaluations by following the script and not bouncing around.  I think I should go the functional limitations first, then go through the past and history.  Goal this week is to complete CPI. 

Tuesday 7/8/2014  8:00am-5:30pm

Today we had a total of 9 pts with one being cash payment patient.  Usually my CI works with the cash paying patients because he said its easier to document because you do not have to deal with insurances.  I had the opportunity to write 100% of the soap notes for my patients which I saw about 4-5 pts throughout the day.  I got the opportunity to work on balance, hip joint mobilization, reassessing progress through goniometry.  I realized I am becoming more conscious of over dosing of therapeutic exercise.  I notice I am asking and looking for pain related answers and questions.  The challenge I had yesterday was being “unsupervised” because I was solely responsible for the care of couple of the patients I interacted with while my CI was in the treatment room with the door open to supervise me if needed.  I felt independent but also scared because I feel like I need more feedback and supervision.  I know I am becoming more efficient but I have a hard time managing patients who want more physical therapy and are talkative which makes it difficult to “kick them out”.  This affects my production in the future and pt care also because then it will disrupt the scheduling and timing a pt deserves. 

Wednesday 7/9/2014 8:00am-5:00pm

Today was a day dedicated to fitness and supervision of post-op patients and their classes.  I was able to meet with my CI and the personal trainers to further develop post PT fitness, wellness, and health programs.  The challenge today was making time and going over the midterm with my CI.  I see need to complete my portion of the midterm and inventory.  I still am having problems knowing when to speak but I think as the patrons of the class are getting comfortable with me, they are beginning to ask for more feedback which gives me practice to speak up.  At the end of the Essentials class, I was able of to instruct a cool down stretching for a group of 6-13 post PT patients.  I felt nervous at first because it was all of the sudden which caught me by surprise.  I was uncomfortable at first because I usually like to practice but my CI thought it was appropriate to do it now.  This is important for future interactions in the setting of PT because I need to be ready to instruct at the spur of the moment.  I need to find ways to improve on modifications for patients who do not have the physical ability to stretch while standing because of lack of ROM or strength. 

Thursday 7/10/14 8:00am-6:00pm

Today I had a good day as far as a practicing point.  Today was probably one of my busier days as far as managing 2 patients (one usually exercises for a long time and the other who was supposed to be discharged came in irritable.)  Two things in my mind was doing manual stretches for one patient and  guiding the other with verbal cues.  This taught me to always have in thought or in mind a plan b for patients who might come in irritable or sore/achy not related to your treatment.   My other challenge was performing 2 evaluations.  1 eval was for an achilles tendonosis and other for L hip pain.  From these 2 evaluations, I learned that I need to paint the picture as far as a patient intake and not have any missing information of progression of symptoms.  Another aspect I can improve on is being able to find measureable functional limitations for example if a patient cant tolerate “sitting/standing, for how many minutes.  My challenge was that I felt again that I was not organized being able to have a funciotnal assessment and also build on more solid objective measures and outcome measures.  Overall I think I did well today and was able to finish on my documentation during my lunch time.  I need to expand on my vocabulary and find words to express and illustrate what treatment was today.  I need to find documentation exercises. 

Friday 7/11/14 8:00am-12:00pm

Today I came in late because of traffic.  I had the chance to work with patients with LBP, and knee rehab.  I am improving and making progress with patients.  One thing I need to do is apply an outcome measure midway between their course of treatment whether it is 2 or 4 weeks.  Also sometimes it may take longer for  apatien to recover with improving functional limitations.  The challenge today was making sure a patient was challenged enough to have them think they were improving but also giving them options at home where they are able to do it.  Being able to give them resources is another big aspect of pt. advocacy. 


Week 7

Monday 7/14/14 8:00am-5:00pm

Today I came in with total 5 patients.  1 patient cancelled due to migraines and I learn it is important to document that the reason why they cancelled to improve on productivity.  For the rest of the day, it was easy to work with because in the time that was free my CI and I went over our CPI evaluations of each other for feedback.  It was a good learning process and I know now that I am going to be challenged to become a better physical therapy student.  I know I need to speak up a lot more now.  My CCCE Dr. Bryan Coleman-Salgado came in today to go over my progress so far and check up on any problems that I might have or might not have expressed yet.  The rest of the day I got the opportunity to work with a new evaluation on a young male with lumbar instability.  With this evaluation, I was comfortable working through my patient but I still need to learn how to take lead with confidence.  The rest of the patients are becoming familiar for me to work with except for a similar knee patient who I am still having a hard time being in control of.  She is challenging for me because of her personality which I have a hard time working with.  I learned with someone that has medical that they need to show improvement which is only show through documentation.  I will become better in documentation being able to find improvements but realize with a patient that they might not improve which is a travesty.  This will help me practice efficiently on focusing only a few things to see if a clinical significant change is there. 

Tuesday 7/15/14 8:00am-7:00pm

Today was a very busy day with about 10-11 patients for a 2 person PT/SPT practice.  We had 1 cancel today.  I was able to write documentation for about 50% of the patients and document 100% for a new evaluation.  I still have trouble streamlining patients but today I had more opportunity to manage 2 patients. The challenge that I focused on today was documentation on a timely manner which did not happen because I had to document till 7pm but I was able to feel more confident and comfortable managing multiple patients.  Things I need to focus on is to become better with  my evaluation and remembering the important things that should be document.  Tomorrow I will embark on a new journey for the practice as we try to learn and implement EMR and electronic based documentations. 

Wednesday 7/16/14 8:00-5:00pm

Today was not a day for patient treatment but a day of administration trying to implement EMR into the practice.  My CI and I went to meetings all day with the coordinator to learn EMR and how it works.  It was complicated at first but I now can the see and experience the benefit with electronic medical records such as WEBPT.  It makes it quicker, detailed, has many different flow sheets and HEPs, makes it easier to plan and communicate with multiple PTs, admin, and clinics.  It helps to keep complicance with documentation.  The negative is the transition because it will be a slow transition for anyone who is computer illiterate.  Overall I think it will be a great learning experience to go over every aspect of the admin side but also the WEBPT is a great learning tool to work with patients and become better with patient intake. 

Thursday 7/17/14 8:00am-6:00pm

11 patient day where I had to work on about 6 patients and documentation.  I was busying showing my patients exercises.  My challenge today was balancing 2 patients at a time.  I am getting better but I need to also know how to verbally manage a patient without supervision.  The trouble I have is making everything flow and remember my patients therapeutic exercises.  Also some patients need versus want more attention so it makes it difficult to please everyone.  The morning was smooth because I usually use my lunch time to document and catch up.  by the end of the day I get overwhelmed with documentation which is reflective of my time management throughout the afternoon.  The challenge of the day is not to feel that I was doing the work but make sure my patients are more responsible for their care.  I was happy that one of my patients improved with her strength and exercises compared to last treatment which seem like they were two different people.  Its difficult trying to be consistent and stable.  I think this is important for me to see that I will have patients that are successful and some that are not and understand that it is going happen.

Friday 7/18/14 8:00am-12:00pm

Today was a half day but busy for documentation because many of the patients that I am seeing needed either a discharge or progress reports.  The progress notes were for patients who were going to see their physician the next day. I learned that it is important to provide and communicate with the physician because they are writing and prescribing extra treatment or continue the course of treatments for PTs to get paid and authorize to treat.  The progress and discharge notes are good practice for me to revisit my goals and to see if I did reach them or if I did not and why.  The challenge is to get the information, write it in a timely and succinct manner so that when the patient go and see their doctor there is information of physical therapy and how they are doing.  I felt very pressured to write fast but what I learned was that I needed to illustrate what was going on with my pt. in PT. I remembered when I first interviewed with B Stockert and he asked me what didn’t I like at PT and I said documentation but now I know how important it is and it is actually enjoyable when the patient load is not over 13 patients.

This is help me serve in the future to become efficient in documentation and to hone my communication skills with the rest of the medical community.  This helps me advocate for PT and my profession.   


Monday 7/21/2014  8:00am-5:00pm

There was much cancellations this today so I got the chance to work on a few patients.  The challenge today was teaching new therapeutic exercises and also I had the chance to work with my CI.  We went over teaching a patient the core stabilization maneuver of finding neutral core.  But before finding neutral core, my goal is to find neutral pelvis then find neutral core.  I also got to work on shoulder mobilization, central PA for the C/s and T/s, and hip flexor stretches.  It was great to get feedback from my CI as I always get nervous around him.  With the patients today, I got the change to improve my manual skills with the RU and RH joint with a person with tennis elbow and some radicular symptoms to the hand.  I have less supervision when it comes to going through a patient with their exercises and manual therapy.  Overall I haven’t had many complex patients but working through a POC for someone that has chronic Achilles tendonsis.  Much research has incorporate eccentric contraction, so I will focus on that with functional strengthening to progress to small plyometrics. 

Tuesday 7/22/14 8:00am-6:00pm

Today we had about 8 pts total with 2 cancelling or rescheduling.  I am getting better with time management for patients getting about 50% of them out within 1hr treatment and 50 within 1.25 hour.  I am improving with my goniometric assessments pre and post treatment by becoming consistent on measuring AROM/PROM.  This was evident when I performed joint mobilization for a patient s/p TAR(total ankle replacement).  I was able to reach my goal of gaining back DF AROM but need to improve practicing my PF mobilization which is better in the prone position.  I am learning mobilization with movement techniques also such as during a leg press or squat to encourage DF and PF ROM.  At the end of the day, my great challenge came upon when I had to perform a shoulder evaluation.  The mistake I made was not asking the patients’ chief compliant but by referring to the Ransford picture drawing of pain.  I felt unsure as far as progressing my evaluation as I soon realized that I was competent to direct my CI as my PT aide while I was able to focus on my shoulder eval.  I need to remember to clear other joints above and below and not get distracted by other pains that did not relate to the Dx.

Wednesday 7/23/2014 8:00am-5:00pm

Today was more related toward the fitness portion again which is becoming better.  It is good to see patients that transition from PT to the fitness portion because they are now more adamant to take control and charge of their health.  The whole day I work there with patient relations and catch up on documentation on WebPT.  I am become efficient on it as I am able to get a patient in within 1hr.  My goal is to finish documentation while working on my patient intake. 

Thursday 7/24/2014 8:00am-6:00pm

Today we had 5 new evaluations in which I conducted 2 of them which met my goal for the week.  I am become better at focusing on the patient limitations and moving on with my treatment to build rapport.  I realized the challenge for me was transition from the objective then to the treatment. I noticed that I was able to get a new eval and finish within 1hr that included treatment and HEP.  My goal is to do similar thing but to also finish and finalize my evaluation.  Overall I am progressing my evaluation skills but still need to incorporate a functional outcome for the PQRS. My goal is to pick the correct OM during the patient intake evaluation.  This will help me save time in the future to help get more treatment time with the patient to build rapport and also have a clearer picture of what I want to proceed as far as my POC. 

Friday 8:00am-12:00pm

Today was  a half day fill with about 7 patients.  I enjoy Fridays because although it is a half day it feel sometimes as if it is a full day with me trying and being able to manange 2 patients within an hour block to practice on my verbal communication and my hand communication.  I am getting comfortable with my CI to the point I can ask him to do “pt aide” things but I realized within my clinical there is my CI and me only so we both end up supporting each other. 

Week 9

Monday 8:00am-5:00pm 7/28/2014

I am getting better at conducting evaluations but still have trouble teaching pts lumbar stabilization and stretching.  I got feedback from my CI stating that I maybe benefit from taking yoga classes to help with instruction of yoga and classes related to stretching.  The challenge for me is confidently and concisely teaching exercises to a new patient while building rapport.  Overall today was a good day with 12 patients, in which 10 showed up.  This gave me more practice of being able to manage patients.  I got to see firsthand how having consistent physical therapy is important for a patient with total knee replacement.  I saw how missing 10 days gave the patient a plateau in A/PROM.  Assessing that patient, I had to give the patient my clinical opinion where to come once a week or twice a week. I am becoming better at measuring patients range of motion by being able to accurately find the important landmarks.  My biggest challenge is still being able to collect patient intake information, being able to instruction a functional outcome measure, teach therpeautic exercises/modalities, and home exercise program.  Those also include scheduling a patient appointment and writing progress notes within ~1hr or so.  My CI taught me to take advantage of times that are modalities such as ice, heat, and electric stimulation to finish documentation.  My biggest challenge currently is time management, and critical thinking and this comes with experience and hands on learning with feedback. 

Tuesday 8:00am-6:00pm 7/29/2014

Today’s theme was discharge notes.   I was able to discharge a few patients that met their goals and also patients who were going to see their physician.  I learned that it is good ettiqute to write progress notes for other healthcare professions to be on the same basis on communication about the patient.  The challenge was writing a couple in time before they see their doctors.  I also encountered two different type of chronic achilles tendinopathy and a rupture.  I find it challenging working with patients with chronic pain because it can be debilitating and hard to manage.  One day pts with chronic pain seem like they are making a good turn for the better then they show up the next time total opposite.  I realized that I had to deal with both types and always have a back up plan in which if they are exacerbated.  With much documentation, I felt overwhelmed.  The tip my CI gave me that during modalities such as E-stim, heat, and ice I could use that time to document to save me time and help me plan my care/treatment.    I will try to make it a habit.  Reflecting on this concept will help me save time in which I can be efficient and on time so that patients that would come in can start on their scheduled time. 

Wednesday 8:00am-5:00pm  7/30/2014

The challenge today was patient management and being able to shuffle and move patients in and out.  We had about a day’s worth of patients booked in the end of the day.  The challenge was picking the correct treatment and using clinical judgment to see what the patient would benefit from.  Then with that decision picking the best place in the gym for treatment because it is a small gym and having 3-4 people already fills up the space.  I see myself improving because I am able to get the majority about 75% of the patients I encounter and treat in and out within 1 hour.  There is always a challenge of patient management and it gives me a great deal of anxiety assessing the initial contact then proceeding patient to a smooth transition to their therapueatic exercises and manual therapy.  My anxiety comes from trying to articulate myself in a manner where I don’t seem to aggressive with my treatment and patient.  I need to find better ways to cope with my heightened anxiety and channel it to hep me become a better physical therapist in the future.  I know I’ll become better with experience and practice. 

CI vacation

CI vacation


Week 10

Monday 8/4/14 8:00am-6:00pm

Today was a busy day coming back from a long weekend.   I felt tired but I knew I had to stay on focused and engaged with every patient.  I am getting comfortable with PA joint mobilization and having less supervision working with patients.  One challenge today was know what exercises to progress my patient and deciding what exercises would be fit their stage and deficit.  I felt lost because I did not review the patient’s chart as thoroughly as I should have.  For me it was about time management again and making time to review a patients chart but also documentation the treatment prior to conjure up a plan that will help the patient get better.  For example, I had a patient with CLBP but did not review her HEP and it slowed me down from adding and developing her treatment on the therapeutic exercise side of treatment.  I felt that with experience with different patients presenting with different cases of CLBP that I can then have a better repertoire of treatments to help the patients.  Another thing I had in mind today was treatment of RTC tendinitis and whether electrical stim and heat was better or worse compared to continuous ultrasound.  These situations will help me in the future pick my treatment with evidence to support it. 

Tuesday 8/5/14 8:00am-6:00pm

The challenge today was performing an evaluation and documenting on WebPT.  I still have difficulty balancing and streamlining the information I can gather with my evaluation but also I lack the efficiency to document via web based records.  I felt behind with much of my documentation but I see myself improving on the use of my “down” time which is the time my patients are on the bike or with heat/cold/modalities.  This buys me time to document and schedule appointments for patients.  I feel that I am more confident with my documentation and how I treat my patients.  I will have a new hire in the upcoming weeks who is a new graduate and I will be excited to get to learn from 2 PTs.  This will help me in the future because I would like to become a CI for someone else also. 

Wednesday 8/6/14 8:00am-4:00pm

Today like many Wednesdays are dedicated to fitness portion of the internship.  I enjoy the challenge of working with patients who are transitioning from the PT side to the fitness side.  There is always usually a lag or a time where you have to spend a little more time and explanation/extra feedback for patients to learn the exercises safely.  It is a safe transition and great idea to help with each patients’ gains that acquired from PT.  The challenge today is to have patients stretch which is difficult for me because you have to give the certain patient modifications for each stretch.  That is probably the difficult but rewarding thing is when you are able to find a position for your patient to be compfortatel and able to participate in stretching.  Another difficult process is that I always try to get as many stretches I can within 10 minutes or so but I realized maybe 2 or 3 stretches where the patients can replicate and repeat is probably better.  I understand this in the future is not to overwhelm my patients and clients with many but only a few so they can perfect it and master it. 

Thursday 8/7/2014 8:00am-5:30pm

Today was another regular type day working with patients with treatment and documentation.  One of the more difficult things today was explain a patient that I was discharging that person who was not  making anymore progress but did not have the resources to keep up her progress.  It was difficult emotionally because I wanted her to stay as a patient because I felt she could still have progress but the way that medicare worked was that she was almost at her cap.  It would be better if she came back later with a prescription.  The other challenge was teaching a non compliant patient who also needed a caregiver.  The difficulty thing was that she came in in pain and unable to perform her HEP so then I made the decision to go for manual therapy with STM and MFR of the bi UT and mid scap area.  That session helped me build rapport and teach my patient postural awareness. After manual therapy, as I taught her specific postural therapeutic exercise in front of a mirror for feedback, she was able to perform them and only had minor compensatory use of her UT.  I felt very flustered but not hopeless.  I think this was important for me not to over do and push therapeutic exercises first but use manual therapy as a way to teach patients what I want them to do during their therapeutic exercise.  It is as almost as it was practicing verbal and tactile cues.  This will help me in the future in the private and rehab setting to work on my communication and different types of feedback such as mirror, phone, and video cameras. 

Friday 8/8/14 8:00am-1:00pm

Today was a half day with 7 patients back within about a 3 hour window.  Time management was crucial as one of the difficult challenges that seemed to happened on a usual day was patients becoming late.  The clinic and my CI is a type of person who will usually take in a patient who is late and integrate them with the care.  The challenge was patient management when a patient is late.  I felt overwhelmed with what I had to balance among pt care/treatment, and documentation.  The way I handled them was that I had to prioritize who needed the treatment room for manual therapy and the gym for their therapeutic exercise.  Overall I feel that I am getting more experienced when to schedule patients depending on what care I think they need.  It is almost a symphony that I am a conductor for and am better of making this “physical therapy case load” a smooth music piece.  This experience will help me become better at scheduling appointments in accordance to the patient and their treatment.  I am better at maximizing my time. 

Week 11

Monday 8/11/14 8:00am-5:00pm

The challenge today was deciding which treatment to focus on whether to focus on the diagnosis and referral from the MD or to treat something else that is related (lateral epicondylitis or c/s).  I felt that I wanted to treatment both but at the same time treat less as far as manual therapy goes.  It is difficult having to make the decision to find what is best for the patient whether to start doing functional exercises.  I believe I am doing the patients disservice if they don’t come out of therapy with a big sense of exercising and independence with management of their symptoms.  I think this is important for me to always have this in mind and not focus too much of manual therapy but blend in treatment to help the patient become empowered. 

Tuesday 8/12/14 8:00am-6:30pm

Today was a busy day with evaluations.  My Ci and my goals are to document at least 2-3 evaluations with just the laptop via WEBPT and electronic documentation.  Today we have had 3 evaluations with 66% being documented via webpt.  I had the chance to perform an evaluation with a patient s/p RTC and biceps repair.  The challenge was being confident with the patient and letting patients know that I have been through that experience gives me and the patients assurance that I know how it feels.  I still feel like the patient intake and functional limitation are the hardest to get out during the evaluation.  I have trouble with getting specific answers but more yes and no type answers.  I need to work on follow up questions.  I felt that I was almost looking for a needle in a haystack because it is hard trying to find what limits the patients most but I think having outcome measures really bring out the patients limitations and goals.  This I will use more often in the future with electronic documentation.  Overall, I feel that I need to challenge myself to finish within the hour and work on my transitioning and management to the next scheduled patient.  I need to work on better assessment of my patients especially during the SOAP notes. 

Wednesday 8/13/2014 8:00-5:00

Today was more administrative work because usually we take Wednesdays to catch up on documentation and had 2 patients come in to continue care and a new evaluation.  The challenge today was making sure I documented well with a patient who came with many psychological issues.  The challenge today was being to take what is important within a patient intake and being able to filter what I need to be able to write a plan of care, and finish my evaluation.  I felt that I had trouble with sifting through and figuring out the history of my patient.  Ergo, I always feel that I can get better and improve on my patient intake.  Every story is different and every patient has a different MOI, and way of how they got to PT.  I think that is why I love physical therapy because even though diagnoses are similar, you may treat in a similar fashion, the end result is always different and how you manage your patient is different.  What I learned that I should treat each patient equally and that to always try your best to believe in your patient because having prejudgement will affect how I will care for my future patients. 

Thursday 8/14/14  8:00 to 5:00

The challenge today was making sure that I know when to discharge patients and had to make sure we are implementing functional outcome measures for patients.  Recently, one of the patients we did not get reimbursed for because there was no outcome measured used.   It was a big awakening not getting reimbursed for patients that we had worked with for over a month.  Now having WEBPt has made things accessbile for outcome measrues to be used because its easier to bring up and assess.  This is helpful in the future to have better productivity and treatment that is responsive to the outcome measures.  I am progressing and discharging more patients as well as feeling comfortable with the whole process of documentation. 

Friday 8/15/14 8-1

Today was a good where I was able to question my progress with a patient.  The challenge was assessing an outcome measure with a patient who had a caregiver.  The patient seems to have a mild dementia that made it difficult to assess the outcome measure and implement it to see if the treatment was going well.  I applied the NDI to treat a patient with UT pain and tightness.  I felt that I was fishing for answers because I know my patient had difficulty reading for an amount of time therefore it was hard to ask the questions outloud.  I felt helpless but also I know it was important for me to practice that situation but also it was needed because I could show improvement even if it was slight it was clinical important different which I could then prove that my treatment was efficient enough to get more visits for the patient.  I think I am improving with my hand skills but I notice I am too light with my pressure at times and it does not seem meaningful for me because usually my CI has more pressure compared to my pressure. 

Monday 8/18/14 8-5

Today we proceeded to finish attempt to finish the CPI.  It was a good discussion for us to go over especially for feedback.  The challenging thing today was performing an evaluation for a person with a lumbar strain with L flank pain.  The difficulty part of the evaluation was time management because this particular patient was a person who would believe anything they read about their condition.   I had trouble trying to control the patient intake to make sure I get what I was looking for but also screen for differential diagnosis with L flank pain.  I noticed that I felt more confident with my evaluation skills.  But I felt as almost as if I was looking for pain and asking so many specific questions.  The more challenging thing was trying to remember everything I did with the examination and taking the information and writing my POC.  The processes of evaluation and POC have felt less daunting than usual.  From the meeting with my CI, I learned that I need to focus on being consistent with my communication skills as far as being clear and concise especially during the mornings.  I felt inadequate that for so long my communications haven’t improved.  By reflecting on these events will help me improve on my ways of thinking, preparation, assessment, and improvement of my skills as a student and always learn from my mistakes to make my weakness stronger.    

Tuesday 8/19/14 8-5

Today was an overall productive day in WEBPT documentation.  I was able to document for 75% of the patients I seen throughout the day.   I had a total of 8 patients and 2 new evaluations.  1 evaluation was  a pt s/p lateral menisesctomy.  The challenge was that the patient was given a protocol and it was difficult to figure out certain exercises without any explanation.  My CI and I had to find out what was the limit as far as PROM was.  She was status post 5 days.  My goal for her was to have her profrm exercises at the hit  and quad sets.  She had a good prognosis because she was a young 50 yo female who was very active and strong.  I felt lost and confused because there was a lack of communication with the protocol however there was some precautions that the patient brought in.  This is important for me to reflect to have more experience and deal with the many types of post op protocols and certain doctors/surgeons.  Ultimately helps me communicate and have an open diaglogue through the patient to their surgeon which is important to be on the same page and give the patient the best care possible.  One of the more interesting things today was working with a patient who was s/p L/s fracture and kyphoplasty.  He came in a FWW and had trouble with strength and bed mobility.  We working on quad sets, mat angels, using the physioball to help stimulate a bridge action.  I was impressed to the knowledge my CI had within a SNF and neurorehab unit although this was a private outpatient PT office.  I believe having experiences in different settings will better equip my tool box with skill sets to be proficient in any setting. 

Wednesday 8/20/14 8-5

Today was the first day my CI hired a new PT/PTLA who was a new graduate from Montana.  My CI and new graduate went over some of the evaluations and are transitioning to WEBPT.  I taught some of the documentation techniques to the new grad while performing an evaluation.  I feel that my role as a student sometimes have been put aside because of my CI trying to balance his business, practice and staff.  The challenge today was working with my patient with a shoulder/neck injury that is related to dysfunction.  I been teaching some of the postural exercises but it was a good time to ask the new grad about certain exercises for posture such as chin tucks with combination of scap retraction/ER of GH joint.  I am excited to have a different perspective and mind in the clinic to bounce ideas off of.  Having these ideas and conversations has helped me feel like I was making progress with my learning.  I felt stagnant at times with my CI and felt I needed more attention and structure.  By reflecting on today, I am sure that I am becoming better with WEBPT, back evaluations, and neck postural education.  I especially had a good learning experience communicating with one of my pts caregiver about posture.  This is important for me to get experience with the patients caregivers and anyone related to the patient and pertinent in their healthcare. 

Thursday 8/21/2014 8-5

My challenge today was working with patients with minimal supervision.  Recently, I got an increased workload as well as less supervision.  My CI has told me that my notes and documentation have been improving.  I am improving on my efficiency and also following up on progress notes.  I was able perform an eval on a patient with lumbar sprain.  Also I got to see the change of a person with a chronic achilles tendinosis improve through report as well as objective data.  I was happy to say that I felt everything today was coming together through the treatment side, and documentation end.  The challenge today was trying to document on the same computer and sharing it within my CI and the PTLA’s window of time each person was treating their patient.  I felt rushed but also calm and concise with my words and evaluation.  I think reflecting on this is important to see that I am making progress and that sometimes there may be struggle or stagnicity when it comes to treatment.  In the end with discharge and positive and negative affirmation makes PT all worth the challenges. 

Friday 8/22/2014

Today was a good busy day with almost 7 patients within 1.5 hours.  It was a good chance to work with 2 other therapists (my CI and the new PT).  I was able to get good feedback from both as far as time management and also communication about sharing time with the treatment room.  Overall it was a busy morning but slow afternoon with 1 new evaluation.  The challenge that day was preparing and working with my CI and the new PT while we all evaluated a pt. with bilateral TKA.  The challenge was being responsible to pointing other observations and tests as we all tried to make it a smooth evaluation.  I felt prepared to figure out what I needed to communicate with the patient for i.e. management of symptoms and expressing goals for the patient coinciding with their goals.  I have felt that I still have problems and difficulty dealing with patients who were more type A and aggressive because they are in pain.  I have been improving on the way I speak to my patients giving them confidence and reassurance. 

Week 13

Monday 8/25/14 8-6

Today, for the majority of the patients I was independent without much supervision.  My CI has given me the opportunity to treat under my own with some supervision from the other PT.  The challenge today was trying to figure out one of my patients who came in with edema in her R foot.  She also has COPD and I haven’t had much experience on what to work on.  She needed exercises and I had a hard time trying to see if I needed to refer her to another physician for follow up with her edema and COPD.  I believe this is good practice for me to communicate with other health care professionals for the sake of the patient. 

Tueday 8/26/2014 8-5

The majority of the patient today were LE related such as s/p trimalleor fracture, and achilles tendinosis.  I also got the opportunity for work on my manual skills for a s/p RTC and decompression of a Ri shoulder and also a patient will bilateral TKA.  The challenge today was managing a patient who came late and needed to warm up.  I decided instead of going with therapeutic exercise first, I started with manual therapy.  That made me feel lost as my plan was different but I learned that switching the order was beneificial for the patient and gave me time to catch up with their status because the patient saw their physician the day before.  I think a it was a good success because my patient came back with her prescription and POC signed.  From there my CI taught me some ways to increase range besides joint mobilization which was PNF stretching with the foot.  I then took those concepts to help me incorporate that my treatment of manual therapy on a patient with a RTC repair.  I feel more confident with my manual therapy skills and being able to reassess patients symptoms and AROM.  As this is important for me to have a good set of manual therapy skills to become a good manual therapist  in the future to give my patients good treatment. 

Wednesday-Friday 8/27-8/29

The last few days the challenge was being able to communicate and work with the new PTLA to be able to then have sufficient organized methods to be able to hand over patient cases.  I felt that I was giving away patients that I have built relationships with and rapport with.  As I reflect, I know that it is important for documentation to be submitted on time, and able to be replicated by the staff there.  It was hard to say goodbyes but easy to move on this clinical knowing that I have learned a good deal about PT and everything that goes behind the scenes of an outpatient private practice with only 1 pt. 

Me and Ariana at Jeff and Yvette ’ s wedding. Second one out of the dorms to get married.

@foodkarma always making good quality love. #jcyt2014

13 weeks with my CI. How my hands feel after manual therapy. Had an awesome experience. Can’t have ups with the downs and can’t have progress without struggle. But you can have is a positive attitude. 2-man clinic.

School and education will always be an important value to me. Wouldnt have gotten the opportunity to chase my dreams of taking care my family one day and helping people if it werent for the youth, outreach programs and people working in the school systems. Got these school supplies for the kids and the future. Thanks everyone for their donations. These will go to the foster youth of the 831. Let’s Get it. A setback is a setup for a comeback. #blessed