The “art” of documentation? Yes, art…and the way things are going in the therapy world today….hopefully not a lost art!
Of the 6 definitions of “art” listed in Merriam-Webster, 4 could be applied to the work that make up a part of every PT, OT and Speech therapy visit – documentation.
- Skill acquired by experience, study, or observation
- An occupation requiring knowledge or skill
- The conscious use of skill especially in the production of works
- Decorative or illustrative elements in printed matter
Didn’t know you were an artist? Well, you are!
You name it, therapists produce it…all kinds of art! Evaluations, progress reports, daily treatment encounter notes, insurance review notes, appeals and discharge summaries. All which require the “conscious use of skill“… “acquired by experience” working with patients and “illustrated in writing.“
Just like Webster said!
In recent years, however, therapy documentation in the SNF setting has taken a “turn” away from the art of things. In part, this can be attributed to the transition from paper to electronic documentation. This transition has made a huge impact on therapy documentation….some positive…some not-so-positive.
The positive:
- Legibility
- Portability
- Streamlined process
- Clinical decision support and prompting
- Communication and information sharing across disciplines
The not-so-positive:
- The frustration with shared devices for staff which results in abbreviated, rushed documentation (8 therapists sharing 3 computers=frustration)
- The expectation that “point of service” documentation would increase efficiency and productivity in an already productive-crazy environment, again, resulting in abbreviated, rushed documentation, often done “not-at-point of service,” rather while trying to eat lunch or “off the clock” (Ask OT staff how they use point of service documentation in the middle of an ADL?)
- The over dependency on technology (Do you rely on your computer program to tell you the rules and notify you when documentation is due? I hope your computer software read the Medicare Manuals!)
- And most importantly, the loss of the ability to truly individualize patient documentation and thus, tell the whole story
There aren’t enough drop-down box choices to tell your patient’s true story.
What was once an art, or creative process of telling a story about our patients and how we were going to help, or restore them, has now become a more mechanical process of pointing, clicking and typing. Somewhere along the line, therapists transitioned from “creating” patient-centered documentation “by hand” to “inputting” a laundry-list of treatments performed each session…oh, and now we throw in some extra verbiage to show skill….and sometimes the therapy documents are too crowded and cluttered with pre-canned phrases that strung together, don’t make sense to a reviewer.
Recent therapy chart reviews from the SNF setting have revealed that the transition to electronic documentation has often resulted in repetitive language, copy and paste verbiage from 1 document to the next {please fix your typos before copying and pasting!} and lack of individualization in the plan of care and approach. There is typically ample wording…{we know therapists can write and write…} and based on the “big words and canned phrases” from electronic documentation, it may appear to the reviewer that a lot of “skilled stuff” was done; however, a “story” is often lacking.
The assessment, goals and plan of care for each patient begin to look the same. It becomes difficult for a reviewer to see why therapy was reasonable and necessary for a particular patient.
- Example 1: In your assessment, if all your patients “present to therapy with decreased strength, decreased balance and gait deviations increasing fall risk,” then congratulations, you just described 50% of the population over 60, most of which do not need therapy. Unique assessment findings are needed to support your proposed plan of care – and a reviewer {or another therapist} should be able to read your assessment and pick your patient out from a gym full of patients. Can they?
- Example 2: If your Part B resident’s 60 minute daily treatment note of therapeutic exercise and gait training looks the same as your 30 minute note for therapeutic exercise and gait training, not only have you lost your story, but a reviewer will surely have a problem accepting your treatment as reasonable and necessary. The amount of time spent with a patient during a treatment should be evident based on the content of the daily note. What? You don’t write a daily note for your Medicare A patients? Yikes! That’s a story for another blog!
So What Can You Do?
Just as each therapist has a different technique and approach, each also has a unique documentation style.
Have you ever covered for another therapist and had your patient tell you that “you do it differently” than the other therapist? Not better, not worse…just different?
The difference may be in how you instruct, how you teach, where you place your hands, etc.
This is the “art” of our profession… carrying out the “science” of our profession.
As therapists, we are all part-artists painting our way to our patient outcomes. We all get to the finish line but how we got there, our “pictures,” may look a little different.
The same goes for our documentation style. Just as we do not all treat the same, we do not all write the same. It is important that regardless of our specific electronic documentation system (EMR), we all maintain the ability to tell our patient story.
Therapy professionals can’t point, click and create “art.” We need a canvas. Use your canvas to narrate the purpose of your treatment. What are the patient problems and why do they have these problems? What will your services do for your patient? What skills will you use to make a difference? And even be so bold as to document what the outcome would be if your patient stopped receiving therapy services!
If your electronic software system (EMR) does not allow for a free text narrative for your assessment, treatment plan and goals, advocate for them! These are the most important portions of your documentation, and “canned phrases” and therapy jargon won’t cut it here. Use your opportunity to write a narrative story – and aim it at the non-nurse-non-therapist reviewer that will likely be reading it down the road to determine if the services were skilled, reasonable and necessary.
Big words do not equal skilled care. More words do not equal reasonable and necessary.
Express each patient’s unique need for services though the art of communication. Explain it simply…
Einstein said, “The greatest scientists are always artists as well.” An unknown author said, “Therapists have the mind of a scientist and hands of an artist.” Both quotes speak the truth!
Our art is in how we craft our treatment, as well as how we craft our documentation.
It is up to us as therapists to hold on to the art of our profession, continue to tell each patient story through our documentation and avoid getting swallowed up by the point-click-monotony of a drop-down-box-copy-and-paste world.
Write on!
In Your Corner,
Dolores Montero, PT, DPT, RAC-CT, RAC-CTA
