If documentation takes 5 times as long as client service time, then let’s evaluate your systems! Recently, we encountered a clinician who was required to submit a paragraph for each of her 40 clients in 2 days.

If you have long narratives for documentation, then answer these questions: (1) Are these required by your facility or self-imposed? If it’s the latter, then use checklists instead. If it’s the former, then consider these solutions:

Solution #1: Keep a template and only change 2 sections of the template for each new note.
Solution #2: Copy and paste each clients’ paragraph from the previous note, and make 1-2 appropriate changes only.

Allison Hingley, MM, MT-BC, walks us through some problem solving below. Be proactive, and take action on this! After all, one of the best ways to curb burnout is to make your life easier. Hit play below –

Kaleigh: Microsoft word documents at her nursing home job are much too time-consuming. She has to do one document or a paragraph about a patient’s responses per client with 24 clients on Thursday and 20 clients on Friday. Wow.

Allison: Okay. So here’s my question. Are you having to document them? So you see 24 people on Thursday and you have to document on all 24 of them each time you see them.

Kaleigh: That’s what I would assume. But Marianne, maybe she can type in and let us know.

Allison: Because I’m wondering is that a facility requirement or is that something that you put on yourself thinking like that’s the best way to document on them? Cause I’ve noticed in talking to a lot of music therapists, they think that they need to have a narrative. Every time you see somebody, and I’m here to tell you that it’s perfectly okay for you to say, check this person came check we worked on these things, check this is how we did it. And then have their own different groups in different floors and then have a narrative to kind of summarize their progress. You know, every other week or monthly, especially in longterm care where you’re going to have the same people for a very long time. They’re in different groups on different floors.

Allison: So if it was me, if I was able to structure the paperwork myself and she may not be able to because the facility may not let her, but if it was me, what I would want to do is have some sort of form where I, um, and this is the form that I use this summer when I was doing a grant based program, I had an attendance bar for a person and underneath I had a narrative and then another attendance bar and then a narrative so that I could fill in, you know, which days they were there. And then when I was doing their narrative, I just put the date in parentheses and a colon and typed in whatever was pertinent for that person for that day and kept everything in the same file for all of the patients for the same group for four weeks at a time.

Kaleigh: Awesome. And it seems like she does have to do it monthly.

Allison: Okay. Yeah. That it’s time consuming. If you just sit down and do it once a month, that’s, yeah, that’s a lot of people. But again, if you have the paperwork that’s designed where you just click and say, Hey, they were here and we did this, and that’s great. And then once a month you kind of just update. If you just update it monthly it’s easier to do it if you keep everything in the same file.

 

Documentation Made Easy CMTE Course

If you’d like to REALLY dig into documentation systems, then check out Allison Hingley’s Documentation Made Easy CMTE course. ON SALE 1/14 for 5 CMTES!

By taking the course, you will:

  • Get the recognition and acknowledgement you deserve from administrators by knowing how to submit meaningful, attention-grabbing reports.
  • Feel valued and impactful in your data collection processes and report submissions
  • Learn how to manipulate and create fillable, HIPAA-compliant Word Documents and Spreadsheets.
  • Understand how to use Google docs in a HIPAA-compliant and highly efficient manner.
  • Deeply explore differences among group and individual intake forms, assessments, care plans, and session plans… each for pre-, during-, and post-treatment stages.

 

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2-Step Process To Discover Your Biases

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