Clinical Documentation Repetition
I entered the field of human service with a mindset to help people help themselves. I believed that we all deserved the best that life offered. Many of us that have recovered or have been exposed to significant suffering choose this field. Often we bring our own ideas and concepts of recovery into our practice. For instance, we recommend setting a schedule, get up each morning at the same time, prayer and meditation, shower and get ready for the day. Schedule a meeting for each day early on in the recovery process. Get a sponsor or a mentor and call them. Build a mutual support group. Of course, there are many skills and techniques but you get the point.
When I train clinicians I make recommendations on how to structure their work life as well. Of course, I am quick to point out that your work is not your recovery and taking care of yourself is of the utmost importance. As a ZenCharts trainer, I paint a picture of how Zen functions and how we laid out the user interface. Clinicians always understand as if a light goes off in their head. Especially the visual clinicians.
I often state that there are two basic types of clinicians. The clinician that is great with paperwork but not so great with their people skills and the ones that are great with people, they are engaging, their caseload seems to be more engaged in the process and they are able to connect with their clients leading to extended stays and better outcomes, but, and this is a huge but, they tend to be not so good with their paperwork. We all know that if it is not written it didn’t happen! Of course, there are the unicorns they are great at both, yet they are far and few between…
We built ZenCharts to be more than the electronic version of a paper chart. We built it to enable the great clinicians to do their jobs more efficiently and effectively. We offer Clinical Decision Support tools like our Treatment Plan builder with outcome measurement tools integrated. Yet, it still comes down to the clinician allotting and spending the necessary time to plan, reflect on treatment progress and document their encounters.
When I was trained I got the traditional advice, 50-minute session followed by 10 minutes of documentation. When you finish your session do your notes! Schedule time for follow-up and other required documentation. Yet, in reality, when I finished a 50-minute session I needed a break. I needed to be on top of my game for my next session and the documentation needed to wait! Now in the days of contracts and grants, my paperwork was for documentation purposes and compliance only and not to ensure the UR team could bill for the service. But that is for another article.
Over the years I learned that I could keep up if I scheduled my day in advance. I know that the best-laid plan is apt to fail therefore I needed to be flexible, I mean who can predict a breakdown or emergency on any given day? So as we built ZenCharts we considered this predicament. In response, we built the “Dashboard.” When I train clinicians and supervisors on its use I suggest the first hour of the day be set for Dashboard time. So let’s take an example, yesterday as a therapist I had two groups, two collateral contacts, and three individual sessions. After each group, I immediately open my group note and do the attendance. I note any irregularity or feel of the group in the group documentation field. I can then defer the rest of the individualized notes for my dashboard time. After each collateral contact, I immediately open the case management note or whatever note my agency utilizes and document the time and contact person information, I can then defer the note for my Dashboard time. After each of my individual sessions, I open a clinical note, note the time and possibly the mental status radial buttons if I have time, then defer my notes for my dashboard time.
My dashboard time is scheduled first thing in the morning. For me, an hour before any clients hit the floor. I open ZenCharts, select my dashboard and start with my notes from the day before. I finish my time by auditing two charts on my caseload and two charts of my colleagues if my agency utilizes cross check audits. This is a maximum of one hour and I am doing it with a fresh head!
If you make suggestions to your clientele to build repetition, consistency and setting a schedule, well, why not do it yourself?
Dan Callahan, LMSW, MCAP, ICRC-ADC