Which type of DOCUMENTER are you?

In the therapy world, it is not easy to manage both providing effective treatment and completing our best documentation. How can we balance the scales to reflect that we can be just as effective documenters as we are clinicians?

First, we need to be honest with ourselves and determine what type of individual documenters we are, as this will help us articulate how we best can change. No matter which habits you have formed, there are ways to elevate your documentation into a clearer picture. Challenge yourself to read each of the unique documenter characteristics below and conclude which one(s) you can relate with the most! Use the associated tips as a starting point to improve and re-focus your documentation.

1. The Savant

If someone were to read your documentation, they may need to google search what half of your terminology means! Use of long-winded, academic jargon may certainly display that you were a top notch student and earned your degree, however it does not help with painting a clear picture for those who are not your peers within your field.

2. The Generalist

When someone reads your documentation, they likely will not have many details to understand the clinical reasoning for what you did! Broad strokes often leave your reader wondering what the point of treatment really was and how it relates to the overall plan of care. You likely forget to justify what you did with how it relates to goals and functional deficits.

3. The Tigger

When someone reads your documentation, they will have a tough time connecting all the dots! Bouncing from one topic to another can leave the reader confused and without a sense of direction. You have similar difficulties as ‘The Generalist,’ however the picture you paint is much more disorganized.

4. The Novelist

When someone reads your documentation, they may give up trying to search for the underlying message! Attempting to find the key points in a sea of knowledge can be exhausting, even for the most dedicated reader. You may find that it is hard to connect the start of care through the end of care while attempting to filter through the excess words. You also may find it difficult to know when to stop writing.

5. The Procrastinator

When someone reads your documentation, oh wait, it may not even be there! Work-life balance, a busy schedule, or difficulty in time-management skills makes it challenging to complete our documentation on time. Putting off your work doesn’t make it go away, instead, it will only continue to pile up and make you feel anxious and overwhelmed.

6. The Independent

When someone reads your documentation, they may question if you listened
to the guidelines provided at all! Functional limitations, skilled needs, medical necessity, patient progress, etc…these all are required for a reason. You may find that you don’t fully understand what is required within each specific piece of documentation to justify services and your role as a therapist.

7. The Equalizer

When someone reads your documentation, they are able to gather the exact message you are trying to convey! Writing with clarity, consistency, and directness within a short story that anyone could understand is the way we should all strive to document. You can connect with any reader, helping to obtain successful reimbursement and perpetuating a seamless continuity of care.