By Haley Burress United States
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.
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:
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:
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.
Here are a few ideas to inspire you to adapt some of your daily, weekly, and quarterly practices.
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:
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:
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.
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!