Discipline for Closure

I see that the new President danced to the tune "My Way", during one of his inaugural balls this past weekend. When the persons you serve feel their uniqueness had been honored for a successful outcome, and that our evidence based practice patterns give assurance of quality, reflecting the trends of the population - then the persons served feel this SLP has done the work their way. Our therapeutic alliance successfully cemented, we are there to give focus and assurance for quality service.

Quality service dictates that we communicate our work well, in addition to training persons to swallow and communicate. We are charged with clear and omnipresent responsibility to document and transmit our clinical visits, with time windows smaller than larger. With documentation and sharing amongst the stakeholders grown large in importance for today's SLP clinicians, being a better SLP requires calm daily discipline to get the writing done. I speak with the bitter pill of experience on this issue, lodged in my valleculae. The years have taught me to drink, drink and drink SOME MORE til the job is done. Here are some ingredients in that pill, so you may not have to suffer my gagging and such.

* Expect, demand, and hold out for someone to MENTOR you through a new documentation routine, after it is introduced. Who wants to be singled out as the one who got it horribly wrong? Make sure, if you are being exposed to a system or procedure, that you are working with a peer or clerical staff or supervisor who will invest in your success. Ask questions! Ask the dumbest questions!! If you see a step in the routine that seems illogical or confusing, say so. The worst they can do is discipline you. Since you are expected to make this part of your workday as an SLP clinician RICH, FERTILE SOIL that is tilled  EFFICIENTLY, make sure you are both well trained and supported in doing the writing well.

* How do you do it well? Knowing the procedures after being mentored for their emerging mastery, you BUDGET your time during the clinical day to get the writing done. Think forward from the time of your visits with your persons served: there are folks in business operations who want to see the daily numbers; there are medical people who benefit from your data and interpretations to move forward; there are clinical coordinators who wish to make treatment of persons served as smooth as necessary. Your notes and reports are extremely vital cogs in the machine that help keep these parallel processes moving, towards the outcome all desire for the persons served.

* And then, how do you write a succinct, clear and focused note or report? Write a lot, so that you are not intimidated by the tasks of writing a lot on a daily basis. Train to relax during the writing task, so that you do not lose your focus for the information you will be sharing. As your work requirements may ask for specific wording to make a point in the person's clinical narrative, you may discover some recursive or stereotypic language helps you make the clearest statement with the least possible struggle. Like it or not, healthcare documentation is under the same push for productivity that drives the entire US economy. If we can write more widgets, while making the widgets clear, powerful and timely, then we are achieving the primary goals for our person served: giving her/him the business!