My first charting and orders!

Today, after interviewing my first patient yesterday, I finally made my first entry into a patient chart (a rather long SOAP note) and wrote my first orders! While I was writing the SOAP note, it just felt like any other assignment and write up I've ever done. But, I'd be lying if I didn't smile a little when I put it into the patient's chart. It's different when you're writing it as an assignment, or writing it after you've actually done an assessment, know what's going on, and are part of the treatment team.

As far as my first order goes, I've decided to try and get my patient off of daily anti-psychotics, and give them a long-acting, once a month injection instead. Before I can do that though, I had to get blood work to check how fast he metabolizes the medication, to make sure I get the dose right. So, writing an order for lab work was my first official order! After putting the SOAP note in the chart, Dr. Gray brought me the medication book (where orders are written) and told me I forgot to write the order. I told him that I hadn't forgotten, I was just waiting until I typed up the note first. What I did not tell him was that there was NO WAY I was going to forget to write my first order! So, it's there now (countersigned by him), and will be done sometime soon. Once it's back, I'll be able to write my second order, and first medication order. I don't quite feel like a doctor yet, but I'm getting there.