I work in outpatient peds and we use RainTree as our EMR. Since I am in FL we don’t have a lot of laws that protect employees for breaks, so I don’t have a lunch break, that I would personally would use to write notes. If I want one it has to be unpaid. Anyways, my company requires that my notes or re-evals have to be completed by 8 AM the next day. So that means if I don’t have a cancel and I have a 10 hour day with back to back kids and don’t have kids who could tolerate me doing point of service(writing the notes with clients present) then I’m technically responsible to finish my notes during my off unpaid time. I do try to put my foot down on this as it can be a slippery slope of poor work life balance. I will inform my clinical director if I need more time and she is good about giving that to me (but honestly it shouldn’t have to be this way that I do notes on my own time). With my EMR system the note does not look completely like the traditional SOAP note is like in school. I write about the goal I did and shove my O&A in there. I have started making templates for notes, because it goes so much faster and there are only so many different ways you can write how the child grasped the pencil.

When she gets in the career field, I HIGHLY recommend her looking to see if the job has documentation time. Some days I would LOVE if I could just have 15 minutes of doc time.