Oh how time makes fools of us all.
Sometimes it seems as if there is too much time. Other times it seems that it is going by far too quickly!
Yesterday, when I thought I had time to sit down and blog, I asked my twitter followers what they wanted to hear about. Carolyn Daschinger responded that she would like to hear about my documentation procedures.
The good news is that this is a good topic, and easily addressed!
Since the majority of my current case load is individual clients, I’ll talk first about my documentation procedures for them.
Assessment: I utilize the Individualized Music Therapy Assessment Profile when appropriate (it’s pretty geared towards kids). I only use the IMTAP as a jumping off point to my fuller and more detailed assessment. With the assistance of the IMTAP’s results, I do a full write up, typically 2-3 pages, addressing the clients strengths and needs throughout the domains of communication, academics, behavior, sensory, emotion, motor, music, and social. I also set initial goals and objectives here. When this is finished, I submit a copy to my records (ie. the file on my hard drive labeled with their name), and to the parent or caregiver for signature and approval.
This is really important to me. I want to have the caregiver’s approval on my assessment because clients can act differently in a new setting. I want to verify with someone who is frequently around them that my observations are consistent with day to day life so that we don’t spend time chasing a goal area that isn’t as important.
I just recently changed this! I was writing a weekly S(ubjective) O(bjective) A(ssessment) P(lan) style note and submitting it to my files and to parents, but I have just recently moved to writing a once weekly narrative style note and submitting quarterly SOAP style reports to the parents.
I’ll let you know how that goes when we send out the first one!
I plan on doing once a year re-evaluation for my clients. We haven’t reached that point yet, so I’ll let you know how it goes when we get there! My plan is to have a sit down with the caregiver, review the previous goals and objectives that were met, and to discuss future goals and objectives (both from their perspective and my input).
My groups are either somewhat in flux or through another organization at this point. However, the primary documentation I do for my groups is an initial assessment of the participants and their areas of strength and need, and then a general progress note addressing if the group objective was met and any outstanding behaviors or observations as related to each participant. These notes are fairly simple, just with the goal and objective written across the top, whether or not it was met, and then a brief narrative of the session.
I feel like this should be longer! As my business grows and different things come my way, I fully anticipate everything to evolve both to meet my changing needs as well as the needs of those I provide service to.
Let me know what you do for your documentation in the comments. Do you try to keep it to a minimum or are you on documentation overload?