The Memory Unit OT

Raise your hand if you’ve ever made it to the end of your work day and you have ALL the treatment notes to write.

I know I’ve been there. I also know I’ve heard TONS about point of service documentation, and I’ve often felt inferior at it.

I remember when the conversation first came up in a team discussion with a clinical development director from upper management. The conversation was less than helpful.

The clinical development director basically said that there was no reason a therapist should be documenting outside of the treatment session, point of service documentation was expected, and all we had to do was set the patient up with some sort of supervised exercise, or document when the patient was taking a rest break.

On paper, this all sounds well and good…. but what happens when you actually apply this to real people?

What happens when those real people have neuro-cognitive impairment? If they require hands-on assist and support for 100% of the session, am I supposed to just ignore that because I’m required to do point of service documentation?

Admittedly I haven’t found the perfect solution. But I have been able to identify strategies that {almost} always work on the memory unit.

Some of these have come from my own trial and error, and some come from the advice of other therapists, but I hope you find them as helpful as I do.

1. Set a timer. This doesn’t have to be a timer that your patient can see and reference. The timer isn’t for them it’s for you. If your session is schedule to be 60 minutes, set the timer for 50-55. Give yourself a little warning when the session is coming to an end so that you can tie up loose ends and leave yourself room to document the session.

2. Use the last 5-10 minutes of the session to transfer care to another staff member. The reality is, if your patient requires 100% supports and supervision to engage in a task and remain safe, you’re likely not just going to drop them off alone in their room at the end of your session. You’re going to need to transition them into another room or activity, leaving them under the care and supervision of another staff member. Don’t wait until the very end of your session to do this. Give yourself 5-10 minutes to make this transition, and then document your daily note once the patient is settled with the next staff member. (This is where setting a timer can be very helpful).

3. Utilize your rehab techs. Firstly, if you’re working in a setting with rehab techs, thank them and encourage them every day. They are SUCH and asset to a rehab department. Secondly, rehab techs are often the ones who assist with a patient’s transition to a restorative program (sometimes they are even the people who run those restorative programs). Incorporating rehab techs into your session will not only offer you a second set of hands (thereby giving you a few free moments in a session to document), it will also empower you and the tech to execute a solid restorative program after therapy discharge.

4. Work towards sustained attention. Let’s think practically about the long-term goals of therapy intervention on the memory unit. There are many instances in which OT services are used to promote sustained attention to task in order to maximize the patient’s quality of life and decrease their sense of feeling lost. In other words, we’re trying to help them attend to task for longer than 1 minute so that they can more appropriately engage in their environments and have a sense of purpose. You may need to rely on some of these other strategies in the beginning, but as your course of treatment progresses, you’ll likely find that your patient can attend to task for several minutes, if not most of the session. That’s when you’ll find a few minutes within a session to document.

5. Take quick paper notes between sessions. When all else fails, and you just can’t find the time during or at the end of the session to bill for your documentation time, jot down a few notes on paper before you move on to your next session. This will at least help you keep track of what you do throughout the day, and should shave off some time at the end of the day when you’re writing all your treatment notes. (Stay tuned for tomorrow because a freebie to help with this is coming your way!)

If you have any other strategies that help you with efficient documentation, definitely share them in the comments! Like I said at the beginning, I’m certainly not perfect at this and I would love to learn some more strategies.