Systems in Music Therapy: Session Documentation

There are systems involved in every thing we do as music therapists - even documentation. For me, documentation is a professional responsibility that is not required by my administrators. This translates into several facts that affect how and when I document. First, I can document in the manner and style that fits me the best. This is a good thing. Second, I can set my own requirements and timelines for documentation. This can be a good thing, but can also mean that I am missing something important to notate. Third, if I decide to change documentation formats, I can do so without talking to other people about it.

I have spent some time thinking about the nuts and bolts of documentation. Check out my YouTube channel here to see some of my Music Therapy Morsels about how I do my job and things to consider when setting up documentation strategies and systems.  

For me and for my clients, the most important part of documentation is response to intervention. Most of documentation includes this type of data. I do not hold any IEP goals (all of my services are considered educational enrichment by my facility), so I do not have any formal goals and objectives to track. Therefore, my documentation is usually mostly narrative in nature. I have established some checkboxes and drop down lists to help me record consistent data in a quick manner, but most of what is recorded involves my judgment on how my clients responded to the music therapy experiences present in the session.

Documentation is a requirement for all who provide human services. If you think about it, even purchasing a drink at McDonalds has documentation involved. This documentation takes many different forms, but there are several universal pieces of information that are essential to include in any sort of record of service.

Let's go back to that McDonald's receipt. I've never really thought about my documentation in this way, but it seems to make sense to me. Let me continue...

I could only find this receipt - sorry that it's not from McD's

At the top of the receipt that I am gazing upon, there is some important information. When I look, the first thing that I see is the name of the store and the location of that store. There is a time stamp, indicating the day and time when the service was provided. There is a list of all the items purchased, including the price of the item. At the end of the receipt, we find the concluding events - the tax, the monies required, the monies offered, and the change returned. There is a notation of how the payment was rendered, and there is usually an incentive to return (at least, that's what happens at my McDonald's). I see many of these same sort of elements when I sit down to document my music therapy sessions.

So, if my McDonald's receipt seems to reflect all this information, doesn't it make sense that our clinical documentation should reflect at least this same information??

So, using this as my format, here's how I structure my documentation (this will be a good quality assurance check for my current format - I'll use this to reconfigure anything that I need to change...):

• Name of client (name of store/name of particular patron) - each client has a unique ledger for music therapy services.
• Time and date of service (time stamp) - I currently indicate the day of service and the amount of time engaged in music therapy rather than the exact times. This was a decision influenced by my administration who focus on how many minutes kids are in therapy and who really don't care if it happened between 1:00 and 1:30 on any particular day. 
• Service format (location of store) - I indicate whether the service is group, individual, lesson, or other using a dropdown menu. 
• Therapeutic Music Experiences (list of items purchased) - I list the names of all the TMEs that we experience during the session. This changes based on the actual happenings in the session - NOT THE SESSION PLAN that I intended! I do not indicate specific goals for each TME in this section - that information is located in my TME file, if anyone ever asks (no one ever has). The important part of TME goals is that they are listed somewhere.
• Attitude, participation, levels of assistance, behavior tracking, and other relevant information (not really reflected in my receipt example, but very important to my clientele) - This information is important to me and to my clients. This part of documentation (all in drop down menus, by the way) allows me to track patterns of response to intervention or to identify preferences and note behaviors of concern. This is the meat of my documentation - the data collection that I take.
• Response to Intervention (conclusion - tax, money, change) - This part of documentation is the most important (at least, to me). This is where I note how my client responded to the music and to the therapist leading the group. I usually try to go for no more than 2-4 sentences (it's really easy when students are fully engaged in all TMEs with a pleasant attitude), but I always write more when it is needed.
• Goal review (incentive to return) - Honestly, I don't have this in place in my current documentation format. This is something to explore. If a client doesn't really have anything to return to do, then why would they? Hm. I wonder what I could include in my documentation to help me focus my treatment to what my clients need in the moment and in the long term. My goals for music therapy groups (as established by administration) are primarily psychosocial in nature and are not formal, so I generate my own goals for each session. There is some long-term continuity, but not much outside my own thoughts. I could do this in a group format - but it would still need to be indicated on each individual documentation database in some way. Hmm.

I am going to take this new conceptualization of documentation as a receipt for services and think about it a bit more. What do you think of this as a model for teaching folks how to document? Do you think there is something missing from this concept? Do you think something is wrong with this as a model?? Please let me know in the comments!!