Back to School: Dreaded D. O. C. U. M. E. N. T. A. T. I. O. N.

Alright!
It is that time of year again.... Back to school. Back to work. Back to the Grind.  Whatever you call it, it means getting in the routine.

Going into my (???) year in the school system, I always find it amazing how I still try to establish new documentation styles that fit my needs, my district's demands, and my students' goals.  Don't get me wrong, I have my scheduling system down. I have my billing entry efficient.   I create an excel spreadsheet as the guide. I print out weekly, because inevitable I lose and received students sometimes on a daily basis. Mark students present or absent.  Highlight them when I have entered the data into the billing system.   But I love discovering new ways to document the progress my students are making.

I know, I know.  You are probably thinking, "What a sicko!"  But I am not (at least in that sense).  I just strive for efficiency.  I can't stand redundancy.  And face it: We live in a world that demands written justification for everything.  If it isn't documented, it didn't happen.  Not only that, Occupational Therapy is a profession that continues to have to prove itself to be distinct, equal, and necessary amongst every other profession out there.  The American Occupational Therapy Association is holding its first Specialty Conference on Effective Documentation in Illinois in October.

When I went to college, I learned how to do SOAP and DAP notes.  I took the Subjective, Objective, Assessment and Plan to heart.  I incorporated it into the hospital and rehab practice with every client and modfied paper work to help things run more efficeintly.  But in the school system, with the caseload being SO different,  I don' t have time to pee let alone provide a meaningful subjective statement each session.

So this year, as I do every year and throughout the year, I search and scour the internet for things that might work for me.  Teachers Pay Teachers is an EXCELLENT site for teachers and therapist to find free and cheap products that can be downloaded and usually easily modified for your specific needs.  It is easy to join.  And in order to download you just have to upload something you have created.  Then share and search away.  Many therabloggers out there, too, are chiming in.

• Your Therapy Source provides insight for therapists incorporating the use of Rubrics, you know those things that teachers have been using for a millennia to grade papers?  You can download free Rubrics for Dressing, Meal Time and Mobility.  Your Therapy Source also has great information about writing S.M.A.R.T. goals to improve specificity and relevance when writing your IEP goals.
• Pink Oatmeal and Eleanor Crawley both discuss how to incorporate cloud based services like One Note for effective and organized documentation.  Don't forget to research security when choosing an online application when writing your comments in the cloud.
• Therapy Fun Zone has a wazoozle load of cost and free downloadable checklists and documentation guides to help you organized your caseload this year.  

So this year, I will start it as I usually do...with a coffee in hand.  But also with tons of resources to try, adapt and hopefully have a successful documentation experience.