The Importance of Clear and Specific Documentation

Sometimes we need to be patient with ourselves and then extend this virtue to our clientele in order for progress to develop. In the midst of this, our documentation and education of those we work with and their families needs to be very specific and clear. If everyone has a clear expectation, not only does progress occur more quickly and clearly, but this also lessens frustration and bewilderment.

It is difficult with goals, dates, funding, and state or facility requirements to do this, but it is needed. In order to encourage consistent progress we either need to be able to document, explain, or break steps down in written form so that patience with progress is seen as such and is valued and developed with consistency.

This week, as I worked with a TBI client, I had seen so much progress in certain areas. However, other needs are surfacing, needs that include the integration of physical and cognitive capacities.

At the beginning, my client demonstrated to me that there were cognitive skills that he remembered and recalled, but because of the various difficulties from the TBI, there was great disconnect between the skills that he could outwardly and easily demonstrate. He recognized people, but could not call them by name. He could recognize many objects, but often got stuck with their label, or repeated the last label he used. This caused those around him to believe he did not remember. The speed at which others expected him to demonstrate remembering threw in a little stress and frustration, causing more disorganization and making demonstration of skills more difficult.

He has come quite far with all of that. So I decided to begin to work on increasing  the rate for which he could demonstrate these skills easily and accurately. As I began to pull up numbers on an iPad (numbers were easy, like a memorized list that slips out without much initial cognitive work) and sing the numeral, he maintained control of the speed of numbers that appeared by pulling them up manually himself. This hand is weak and shaky, so in-between decades he taps the drum to the beat with me.

The first time I pulled this out, I had no expectations for him. He just watched. As he listened and watched the numbers with intensity, he had come so far with speech, labeling, and organizing thoughts, but there were still so many unaddressed physical needs. The shaky hand is steadier as he focuses on the numbers, So I decided to make the shaky hand the priority. As he focused instantly and identified the sequential numbers by tapping them, I utilized his focus on one skill and used the continuity from the rhythmic flow of the tune to help gain more motor control over that hand (which will inevitably help with the speech control also).

My client is remembering, organizing, and demonstrating more and more. He can not yet identify a random number quickly (1-100), can not yet name all those numbers on the spot, nor can he tap the drum steadily. However, it is documented as, attending to each number, tapping the correct number, and tapping so many beats out of so many beats correctly (raising that number for each objective), or tapping the drum in double time to the beat, gains in the integration of these steps will begin to occur. As we focus on the steps, the correct possibilities that the client can demonstrate and other team members’ expectations of him will include more work on the same areas, increasing the rate and opportunity for success and lessening the frustration of skills that are not YET ready to evolve.  This demonstrated progress AND education keeps the ability to receive other services (by insurance standards) open by demonstrating the current possible skills that are currently demonstrate-able. The clients documentation must be able to show his demonstrate-able progress, it must be broken down so that others wandering by, wondering why he isn’t demonstrating the skills they expect. They think these may not be appropriate skills to deomnstrate for the client at the current time. This attitude toward who should receive services still keeps the possibility open that goals are possible, services are needed, and accomplishment of skills is possible. The integration of the cognitive speech and organizing skills, along with the motor areas of the steady hand will take some time. Careful intentions, documentation, and education will allow others to see the tremendous gains being made. Those of us without physical or cognitive weaknesses or difficulties in day to day functioning tend to forget sometimes that our own individual weaknesses have taken time and small accomplish-able steps to be overcome  or dealt with . Therefore, careful, measurable documentation and education needs to occur.

Antoinette Morrison MT-BC