Reduce Time Spent in Documentation

Interested in spending more work hours face-to-face with the kids you serve?  Looking for ways to spend off-work hours face-to-face with family and friends, or at least a good book?  Let's reduce our time spent in documentation.

The trees outside your office window are calling...

 
These suggestions are based on the documentation requirements often encountered by therapists who work in public school systems.  I hope some of these ideas may work for you.

Ways to ↓ Time Used for Documentation:

 

Big Picture Questions:

--Who are the potential readers of your documentation? excluding IEPs

• Eligibility teams (including families)
• Outside professionals working with student
• Peer OTs who may work with student in future years
• You
• Third-party payers (such as Medicaid)

--Who is most likely to intensely examine and utilize the information in your report/therapy notes?

• Eligibility teams
• You

--What documentation is the most critical to making decisions about the student?

• Initial evaluations
• Subsequent evaluations regarding student’s abilities & ongoing need for OT services
• Your treatment notes in your school system's online software program (or paper-based system), regarding student’s progress on goals and/or use of accommodations.

 

To consider:  If eligibility team members and the individual therapy provider are the most frequent users of documentation then the majority of time spent documenting should be spent addressing the information needs of those individuals.   Documentation should focus on 1) informing school teams, including the families, of the student’s status and 2) creating easy-to-use data for decision making by the therapist.  If outside professionals, peer OTs and/or third-party payers require further clarification or data, the therapist can provide it upon request.

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In light of the above-listed questions and responses, how can OTs ↓ the amount of time they spend in documentation of reports and online treatment notes?

 

Reports:  

• Adopt use of a streamlined, customized report template that reduces verbiage while emphasizing essential components of the report.  
• Decrease subjective input.

 

Online treatment notes:

Focus effort on documenting sessions related to:

• a significant breakthrough, change in student’s independence with a skill
• critical information gained via parent/teacher consults
• EOY summary of progress and plan for treatment focus following summer break [this is not a EOY report but a bridge to facilitate speedy resumption of services in the fall]

 

Reduce length and detail in documenting sessions by:

--Documenting the key facts in the session, without adding extraneous details.

Example--try writing, “Student put arms through both sleeves of compression vest, without protest, with less adult prompting as compared to 11-17-16 session" instead of, “Student arrived in classroom, sat at assigned chair and ate his ‘Power Donut” with glee, getting crumbs all over the table, as usual.  After washing his hands independently he demonstrated good interpersonal skills by carefully hugging his best friend and then ambulated over to the therapist, with both arms raised and both hands still coated with sticky crumbs, to assist with putting on his blue compression vest that was lost for two weeks but finally found under the seat of the bus #151.”

 

Use telegraphic writing--pack as much information as possible in the fewest # of words.  Use abbreviations that are commonly used in medical settings.

The 1o reader of your documentation = you.

 

Finalize your online note immediately after writing it.  It takes five minutes to fix a mistake in day/time/minor detail in a note once you alert the help desk of your online documentation provider, or correct the error in your paper-based system.  How long does it take you to go back to a large number of unsigned notes via your online site, review each note and then finalize them all? 
 

If you are using an online documentation system, batch your progress notes--write at least two at one sitting, preferably more.

 

Since our online documentation system doesn’t always populate the data fields with required information, such as the diagnostic code for students, I keep a reference sheet of students and their diagnostic codes handy while I write notes.

 

If you feel like you are shortchanging your students by writing fewer words or details in a note, compromise.  For a student you see twice a week, spend your usual amount of documentation time writing the first note of the week.  Then, practice a shortened approach to word usage in the second note of the week.  Purposely make the second note more succinct.  It takes awhile to get accustomed to not laying every thought out on the page; discomfort is a sign of adaptation and growth.

 

About IEPs:

Be concise, eliminate subjective information: “Jimmy is a sweet, second grader who always comes to school with a kind word and cookie for his teacher.”

Add information about the student’s independence and areas of need that are focused on school performance--it’s unusual to write in telegraphic style in an IEP but aim for brevity.  Does your input exceed the special education teacher’s input?  If so, it's time to downsize your words.

 

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Additional suggestion:

 

At least two of our therapists dictate their treatment notes into their Google calendars, then cut/paste the info into their online documentation.  They love the time they save. 

Wouldn't you rather be outside right now?  It's fall, and Virginia is too beautiful to miss.