Documentation Templates: A Strategy to Improve Efficiency and Decrease Frustration

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WHAT IS A DOCUMENTATION TEMPLATE AND WHY SHOULD I CARE?
Let me introduce you to the idea of the documentation template or “mother note.”  This is a documentation strategy that I learned a long time ago because of my insatiable desire to limit the time I spent doing the one un-fun part of my job.  The concept is very simple: build a note that incorporates all the strategies you utilize in a typical therapy/nursing/social work session and then add qualifiers afterwards while deleting the sections that were not addressed.  So generalize first, personalize second!  This note is essentially a documentation template--it has all the building blocks for proper documentation: what you did, why you did it, how the patient responded, and what you plan to do next time.  

HOW MOTHER NOTES HELP
This technique works wonders for your daily routine and improves you as a clinician because you are better able to divide up your treatment sessions in a logical format since you’ll be aware of how you will document it later.  Whether you start your treatment session with some sort of warm-up and stretching or begin with a basic educational review of safety principles.  Whatever your style may be; create your “mother note” to reflect your habits.

After your treatment session, pull up your “mother note” template and fill in the blanks.  Did your patient require moderate assistance or maximal assistance with upper body dressing? How many repetitions did they do for long arc quad raises?  How was their postural alignment during gait training?  These, and innumerable other qualifiers can and should be added so long as they paint a picture of the treatment you provided and show a chart auditor why your treatment was reasonable and necessary.  

BUILDING A MOTHER NOTE
It’s profitable to create several “mother notes” as you may have various common treatment themes depending on your discipline.  You might consider having a follow up, eval, reassessment, and discharge template; though you’ll inevitably get the most bang for your buck by constructing the follow-up note.  If you’re a nurse, wound care may be a common category of note.  As you endeavor to build your “mother note” or several, gather the common phrases you’re using frequently in your current documentation.  Do you record wound size in cm? Are you describing the wound in one of three ways?  Do you mention color?  As you continue to document your narrative notes, grab a sticky note or legal pad and gather a list of common phrases or qualifiers you use.  You’ll eventually assemble your own personal “mother notes” from these puzzle pieces.

Once you’ve gathered a substantial list of common phrases and qualifiers, you’ll need to arrange them in a logical sequence and string them together in an articulate way.  Everyone knows that documentation phrasing is odd, but it still has to be grammatically correct and sensical.  You don’t want to come across as a barbarian: “me eat cow, I hungry now.”  Syntax is critical!  

Some considerations when arranging your note should be:

1. Do I wish to arrange my note in a linear way with the treatment sequence?
2. Would I rather place descriptions by category?
3. Should I follow a “SOAP” format?
4. What kind of qualifiers do I use?
5. How do I convey the quality of the patient’s performance?

Whatever your determination--be sure to assemble the puzzle pieces for your template in the most logical way possible.  The goal here is to make this note as average as possible.  You should have standard opening and closing statements like “Patient demonstrates improvement in _______ and ______” and “However, pt would benefit from ongoing skilled _____ services secondary to continued need for _______ and ______.”  The objective is to provide intense detail, but avoid having to repeat the onerous phrasing and prose that will give you early onset arthritis or carpal tunnel from typing so much.  What you put in the middle of your note will vary based on your treatment style, but be sure to put the qualifier words in parentheses.  Example below:
“Patient transfer training from wheelchair to toilet.  Pt requiring (min/mod/max) assistance for transfer and (min/mod/max) verbal cues for safety and sequencing.  Pt (poor/fair/good) return demonstration secondary to _________.”

Finally, once you have pieced together all the essentials for your template and have a good Mother Note: you’ll need to know how to use it!  You have a couple of options for use, depending on your company’s documentation system.  If your company uses tablets with android operating system, it might be useful to email the template to yourself and pull up that email by switching tasks from one app to the other.  Once you’ve pulled up the template, copy it and paste it into the documentation system, making sure to edit the particulars to make it specific.  If your company uses laptops, it’s even easier to pull up your templates from a file saved on the desktop or easily pasted on a sticky note.  Whichever method suits you, Be sure to enjoy the fact that more of your evening will belong to you less to senseless repetition.  Have fun as you continue to Hack Home Health!