5 Best Practice Documentation Habits

5 Best Practice Documentation Habits

User Profile By Haley Burress   United States

Found In: Activities Articles

If you didn’t document it, it didn’t happen. Even if you’ve only been working in senior care for a few months, you have probably heard this saying.
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If you didn’t document it, it didn’t happen. Even if you’ve only been working in senior care for a few months, you have probably heard this saying. 

Documentation is an important part of our roles as Activity Professionals, but honestly, it can also feel like charting and documenting takes you away from your residents more than you would like. Here are some tips to increase efficiency with best practice documentation habits.

Why Documentation Is Important

Charting and other documentation is crucial for residential care and helps us to track potential challenges, concerns, or trends. When your Activity Department is documenting well, you can:

  • Notice if a resident has stopped coming to a certain activity suddenly
  • Follow up with concerns quickly and before the problem escalates
  • See which of your activities are the most popular
  • Determine which activities could perhaps take a break or return later
  • Develop more individualized interventions using favorite activities
  • Determine what time of day could be better for a certain resident in regards to participation
  • Share activities that work with residents with other team members throughout the facility
  • Prepare you for family and care plan meetings
  • Be confident your department is ready for federal, state, and other regulatory compliance visits

Related: The Importance of Documentation for Activity Directors (Golden Carers)

Common Documentation Challenges

Spending time in your office or at the nursing station charting behaviours, interventions, and participation takes time. Some Activity Professionals struggle with this time away from residents and activities, which can lead to feelings of stress, anxiety, or overwhelmedness. 

Activity Professionals can struggle with keeping up with documentation for a variety of reasons. Common challenges for maintaining documentation standards can include:

  • It takes too much time
  • Charting takes activity staff away from 1:1 visits, leading groups, or planning new events
  • No other activity staff to share documentation duties with
  • Not knowing what to include in progress notes or care plans
  • Vacation or other time out of the office causes documentation to lag behind
  • No policy or procedure to guide the process
  • No systems in place for documentation ease and success
  • Disorganization or poor time management techniques

Fortunately, even the most overwhelmed Activity Professional can get caught back up with proper documentation. It just takes a few best practices and habits to start your entire department to document successfully without the frustration or feelings of neglect.

Getting It Done: 5 Documentation Best Practices

Here are a few ideas to inspire you to adapt some of your daily, weekly, and quarterly practices.

1. Delegate

As an Activity Director, you may feel that most of the documentation duties fall squarely on your back. While you are ultimately in charge of the activity documentation for residents, you can empower your team to document as well; things they could do:

  • Participation logs
  • 1:1 logs
  • Behaviour logs (as needed)

When possible, designate one or two outstanding team members to assist you with other documentation. This is an excellent way to not only get the help you need but to also acknowledge and honour activity staff members who are ready for a new opportunity. The nominees can help with:

  • Assessments for new and returning residents
  • MDS (Minimum Data Set) documentation and corresponding updates at 5 days, 14 day, 21 days, significant change, etc.
  • Monthly and quarterly notes

In order to be most effective, try to split up your community between you and your nominee so that you can keep up with a certain set of residents in regards to documentation.

2. Open and Close

When I worked in a community, I found it easiest to keep up with documentation when I made it a part of my regular day. While no day is the same in the Activity Professional world, you can create habits by documenting at the beginning and at the end of your day. My team and I called this Open and Close. 

Open the day with 15-20 minutes of documentation duties and close the day with 15-20 minutes. This can be assessment time with new residents or catching up on your notes or care plans. It doesn’t matter what you do during Open and Close, as long as you are focused on documentation only.

3. Document During Care Plan Meetings

If you have care plan meetings in your community on a certain day of the week, clear your calendar for 30 minutes prior to the meetings. Go into the care plan meeting room a few minutes before everyone else and use that time to document and catch up on updating or reviewing goals and interventions.

4. Document During Resident Downtime

If you are feeling the tension between your documentation duties and your time with residents, make your documentation time daily when residents are elsewhere. Breakfast and lunch times are excellent documentation times, and you can find more peace and quiet at the nursing stations if you are using paper charts. 

These days there are also many excellent digital documentation programs you can use to save time and increase efficiency. If you wish to chart digitally, ask your manager for permission to trial Toolkit (by Golden Carers) or another online charting solution.

5.Chart Audit

In order to create successful habits in your team, be sure you are doing regular audits of their documentation. Catch bad habits before they become problematic by making sure participation logs are completed daily and 1:1 narratives are completed after each visit. If you find this isn’t happening, re-educate your team.

How do you keep up with documentation in your community and during your busy days? Let’s share our best practices with one another!

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Haley Burress

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