Not a TME Tuesday - Documentation Talk

I'm very sorry if you were looking forward to a TME Tuesday post this morning - I just woke up with a need to write about something significantly different today.

I was reading my social media posts yesterday afternoon (as I often do) and I came across one that stuck with me. The author of the post wrote about a disconnect between documentation and personal feelings and experiences about the experiences that occur in music therapy treatment sessions. This comment started me thinking about this same thing and how it happens in my life. (The best posts always challenge my thinking about something, and I really appreciate them.)

I responded that I do documentation for my administrators and documentation for myself - something more humanistic for myself and something more objective for those who bother to look at my documentation. This takes many forms, but is something that I do in order to process what happens in my sessions. 

(By the way, I am completely caught up with my clinical documentation as of this morning, so I have done a bit less of the humanistic part of this process lately because of the sheer numbers of sessions that I did last week. The data had to come first. Maybe that's why I have been so resistant to doing my notes...hmm - less of the other part of processing available to me. Something to think about.)

Documentation is something that is necessary to those who pay for services, but it is something that should also be meaningful. I think many of us often miss that mark when it comes to recording our clients' responses and actions during sessions. I know I do.

My facility actually requires little to no documentation of my sessions. Our licensing requirements have a bit more for me to do, but they are only really interested in attendance. The insurance companies sometimes want to know about response to treatment, but they don't often look at the notes for the creative arts therapies to justify their requests for discharge or extension of length of stay. Most of the folks at my job are unaware that I do document every music therapy interaction that I have with every client.

The Art Therapist is in the same boat - she has a professional responsibility to document all sessions, but no real facility expectations. We've banded together to find something that works for us and for our caseload, but it still doesn't really work. It does not really capture what happens during sessions.

I use my session strategy bullet journal-type thingy to process a bit deeper - some of the time. I also use my written journal. I draw. I play different types of music on the piano. I cry. I think through scenarios. I talk things over with the Art Therapist, and we process session events and client responses during peer consultation.

Another thing I do is to view each session as an individual session. Every group is unique and functions like an individual. If you are interested in this concept, I encourage you to buy the following book (Full Disclosure: I get nothing if you buy the book, but I did contribute a little bit to the writing): Treatment Planning for Music Therapy Cases, by Anita Gadberry (2012).

This documentation, that of group as individual, is not something that anyone is interested in but me. All of that thought and processing happens outside of my regular documentation practice. I can tell when I am not thinking more deeply about music therapy and treatment when I lose track of these concepts. I think I will formalize this practice a bit more. I seem to have forgotten that this part of thinking about music therapy is also valuable to me and to music therapy services at my facility for my clients.

Next month, my facility is moving to an entirely new method of documentation. We've been ensured that the new documentation system will accommodate the unique part of what music therapy brings to our clients, but we have had no input into the design, so I am not sure how it will all work. The last time we did this, the documentation was not appropriate for the creative arts therapies. This time, we have been on the list of people who will be using this format, so that helps. I'll be finding out more about the new documentation system in a couple of weeks. I hope it will be quick and easy and relevant to what I do.

It is time to stop talking about documentation and go do the work.


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