Did you write it?

Documentation has often been the near death of my speech therapy career, more times than I can count. I write a blog now so - I must admire something about writing. But until recently, clinical writing threatened to become the black hole where most of my love for the field might be SUCKED! When I was in training, and even following graduate training - good writing was expected but not well taught. You were shown reports in the university clinic, and expected to emulate the style(s) shown in these reports.  That's all!?! That's all good clinical writing is - ?!?!?!?!? Don't you believe it. But, until I had had enough experience in the trenches, writing  many reports and notes - I rarely had more than other notes from which to learn good clinical writing principles.

Good clinical writing is, above all, a record of what you actually do with your patients. The SLP who writes well can tell the patient's story, in ways that not only satisfy the people who pay  the bills. There is also a need to pass along the uniqueness of the person you serve. When you meet this benchmark of telling the person's story, you give your patient more effective treatment that fits these unique needs  The effective clinical record also meets the standards for behavioral applied science, - namely, what you did and what the patient did in response. And, when the effective written record is completed, other professionals who may also serve your patient will give their best informed service.

There are day to day realities to face about good clinical documentation:

1. "If it wasn't documented, the encounter did not happen". The essence of the SLP ''s work then is - the production of the written record. With point of service documentation (performed at the time of the encounter)  being the trend in clinical practice, the record is completed near the time of the encounter. The clinician who can meet these standards is more confident that the record accurately reflects the actions taken in the encounter.

2. "Data-driven" - your documentation provides value for your patient's care, when it contains the discrete measurements you specify to track changes in your patient's behavior. It could be number of correct initial "s" sounds from a word list, or the number of initiations of conversation, or the average duration of a swallow of ice cream. Your data trends drive your treatment. Let your documentation be easily read with data.

3. Writing clinical notes well tells your readers: you are a skilled observer, not only taking good data but telling a good story. It tells your reader how well behavior has been deconstructed to train the core skills, and anticipates how behavior will be reconstructed so your patient can reenter real life. It requires writing with economy to meet reporting pressures, and writing with clarity so that your patient receives appropriate care.