March 1, 2013 Columns

Make It Work: Document It On the Spot

It's common today to hear the "clack, clack, clack" of clinicians tapping on their laptops during treatment sessions with clients.

And this practice—point-of-service documentation—will likely only grow, given increased documentation demands, evolving technology and the push toward person-centered care.

But first, a caveat: The intent is never for clinicians to do administrative work with the client in the room and call it point-of-service documentation. The intent is to provide instruction, cues, direct observation and assessment—and to be more accurate about and reflective of clients' responses through on-the-spot recording.

Mutual benefits

This client-involvement approach is meant, primarily, to help boost client performance: At the outset, the client and clinician together determine a treatment plan and set goals. In subsequent appointments, the clinician provides feedback based on documentation prompts and comparisons with prior performance. Along the way, clients offer perspective on their own progress and treatment response, ideally helping the clinician help them gain insight.

With point-of-service documentation, clients know how they're progressing; consider how they can improve; review their goals; participate in their plan of care; and gain a more positive outlook on therapy and why we are working on particular tasks.

And the approach benefits clinicians, too, by allowing them to save time, keep close tabs on patient progress, incorporate client input into treatment, bolster communication and quality of care, provide more objective documentation, and boost productivity.

Practice pointers

Despite its advantages, point-of-service documentation can be challenging. Although many clinicians incorporate some aspects of the approach, full-scale adoption can initially interrupt the habitual flow of interactions with clients. So what's the key to making it work? Being able to divide your attention successfully and multitask.

Even while documenting, you need to connect therapeutically with the client and ensure effective communication via eye contact, observation of facial expression and allowing for processing time. I'm not suggesting this is easy, but these pointers can make it doable:

  • Be prepared with test materials, forms, electronic tools, clipboard and pens.
  • If permissible, take the chart to the location of the evaluation or treatment session.
  • Ask questions of the client during the chart review, both to verify the information and to begin assessment of the client's cognitive status.
  • Assess the client's current status—obtain subjective information and record objective information, including results of tests and measures performed.
  • Document relevant client comments and objective information as it is gathered.
  • Engage the client in the process. Use the evaluation and treatment session to gain an understanding of the client's insights to his or her condition.
  • Incorporate the client's wishes into the goals—find out what is important to the client and how the client wants to proceed.
  • Ask the client if there is anything that needs to be added, changed or deleted when reviewing the established goals.

There will always be times when full-fledged point-of-service documentation is not advisable. For example, if a client has cognitive impairment, the approach may be perceived as inappropriate or even unethical. In this case, you can involve caregivers in the skilled treatment session and incorporate their perceptions of the client's status. The result is more robust patient documentation.

Similarly, clients with hearing impairments need an environment low in auditory distractions and may need some other process adjustments. Keep in mind, however, that engaging them in conversation is important to furthering their understanding of their treatment.

Not all documentation can be completed at the point of service if, for example, a clinician needs time to analyze test results or the client's performance. Is it possible to review a chart during a modified barium swallow study and at the same time engage the client verbally without appearing (and feeling) disorganized?

Some professionals process more completely without distraction or the pressure to interact with the client while reading or writing. Still, the plan of treatment should not be completed without first validating that it is consistent with the client's wishes.

I should note that point-of-service documentation cannot be an "all or none" proposition—there will always be client, clinician and system variables affecting its advisability. Documentation at the point of service provides a valuable opportunity to put clients and families at the center of treatment. But it is always up to the discretion of treating professionals to determine if this or any other approach will achieve their foremost goal: improving the health and functioning of their clients.

Mary L. Casper, MA, CCC-SLP, is a corporate rehabilitation consultant for HCR ManorCare and coordinator of ASHA Special Interest Group 15, Gerontology. casper219@aol.com

cite as: Casper, M. L. (2013, March 01). Make It Work: Document It On the Spot. The ASHA Leader.

  

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