Yesterday Did Not Go As Expected...But, That's Really To Be Expected

Does this ever happen to you? You head to work full of plans, just to find that one thing has changed all of what you have planned into something new? That happened to me yesterday. I started off with a plan for what I was going to get done during my time as an internship supervisor and ended up just being the therapist. Not at all outside of my realm of experience, but not at all what I was expecting to happen.

My day was full of interesting responses - to me, to the change in leadership, to the ways I was doing things, and just general stuff, you know? The most definite thing I can say is that we all survived. I'm not sure how effective I was as a therapist yesterday, but we all survived. There you go.

I am currently struggling with a couple of non-direct care tasks and concepts that have surfaced just lately. One of them is documentation and the other is a presentation that I am supposed to give (after being postponed twice) on Wednesday. I have nothing to present to this team, and I haven't had anything to give to this team the other two times I was supposed to speak. It's been messy, but I think I know what I want to say tomorrow afternoon in my presentation. It has to do with my other problem these days - documentation.

At my facility, I document things that are not accessed by anyone other than the music therapists. We are not a related service under the IDEA. Music therapy is listed on the IEP as an educational enrichment service provided, but I do not have any representation on the IEP for any of my students. Music therapy is listed as a group therapy service on the Individualized treatment plans (ITPs) of each of our residents, but I do not document on the same platform as the social workers. I take daily notes on all music therapy interactions, but nobody seems to access that information - ever.

Every two or three years, the art therapist and I evaluate our documentation systems and evaluate what is working and what is not working. It's that season around us right now.

My art therapy colleague is moving to a completely different type of documentation - a monthly progress note based on notes that she is able to take during group sessions. I don't want to do this process, so, for the first time in about 10 years, we are going to document things differently from one another. That's okay, but her changes in her format are spurring me into evaluating what I'm doing with my own documentation.

There is freedom in making your own documentation system. With the act of breaking music therapy documentation away from art therapy documentation, I can set up categories that were irrelevant when we both used the same files, and I can develop more music-related responses into the documentation system. I'm trying to figure out ways to make documentation quick (we do over 190 notes per week) and relevant not just to me, but to anyone who may look (I want things to be clear to non-music therapists just in case anyone every bothers to look). I'm trying to figure out ways to make some things self-generating - I hate having to type in the session events into everyone's note. There has to be a way to get this into a self-generating process - type it once and it magically shows up in everyone's note. (Right now, I type it into Word and then copy and paste it into Access. It works, but there has to be a better way!) 

I want to have a series of checkboxes that illustrate what goals are addressed by each therapeutic music experience (TME). I want to have some places where I can further expand on how each TME is addressing goals and objectives. I also want a place where I can indicate how clients engaged - fully to withdrawn. I want to be able to do one note in about 2 minutes, including a statement about how a client responded to each intervention. I envision a table of some sort, but I don't know how to generate it yet. Hm. There is so much to investigate and explore.

I'm watching what my art therapy colleague is doing with much interest. Her new format includes taking brief notes during sessions about response to intervention and number of STARS earned (our campus-wide PBIS structure). She then compiles these notes into a paragraph about each student once per month. I guess I could do something like that, but I really like the structure of daily documentation in the computer. I am trying my best to decrease the use of paper in my life, so leaving the electronic recording for a folder system seems to be a step backwards to me. I also don't have as many opportunities to take notes during sessions as my hands are almost always busy with strumming the guitar or playing instruments or engaging in body percussion. It's hard to write and play live music at the same time. 

As with my assessment process for clients, it is time to do an assessment of my documentation system. I will start with a critical observation of what I am already doing and what others would be more likely to want or need from my documentation (that's where Wednesday's presentation will come in). I will establish some goals and objectives for this system and then start the development process. I expect that it will take some time, but that's the way things go.

For today, though, I have made a start through working through all of this here. I am hoping that my day will go as expected, but I am ready for whatever will happen...I think. I will see.