Masterclass #3 Daily Notes Do's and Don'ts

Hey, can you guys hear me? Okay. Hello. Hi.

Now I'll mute.

Hi. Welcome everybody. Can you hear me?

Yep.

Cool. We'll just let everybody hop on and then we'll mute after. How's your day going? Or night, wherever you are. Hello. Go ahead and share my screen so you guys can start sharing. Oh, that's not gonna work. Share screen.

There.

Can you guys see my screen?

Yeah.

Can I still admit people though? I guess I have to wait. I can't see people. I need to admit. Anyway. Welcome everybody. Hey, Morgan. I'm just looking for. Oh, there we go. My mom is hopping on. Hi, mom. She decided she wanted to watch, so you know what? I couldn't. I can't really share my screen and admit people at the same time. So I'm going to tell you what I'm going to have you start with. So you guys type in where you're from and let me know what you are using for your daily notes right now. If you're using an EMR paper, some IEP thing. IEP online or something. And then so three things where your listening from, what you're using now for your daily notes and the best part, what you will do for fun when you have more time in your life. Lisa, I see you're already having fun laying in your hammock. Yes, my favorite place to be is in my hammock or in my kayak. So type in where you're from in the chat and CPSC portal. I don't haven't heard of that. Maybe it is a New York thing. Is it like an EMR, WebPT Fusion, Google Docs? Hey, Darlene, where in Washington are you friends? It was a really nice day. It's been really hot here and today was just like in the 80s. It was so comfortable. It was actually 109 in my town last week. I couldn't. I don't know if I've ever seen it that hot here. I don't see what you guys are going to do for fun though when you have more time. You got to type that in too. What are you gonna do for fun? Get a dog. Love that. I've been kind of wanting to get a puppy lately. My old girl passed away, so it's been. I'm like, oh, I don't really know if I can do a puppy with so much work. Mm, Port Orchard. Nice. Oh, you have a grandchild. Expect coming soon. Laura, that's so exciting. That is a good motivator. Get those notes shortened. We're probably hanging out with friends. Love It Easy track. I've never heard of that. It's all these things I haven't heard of. Interesting onenote. Crafting. What kind of crafts do you like to do, darling? Travel. I hope we're gonna be free to do a lot of traveling soon. Ooh, be at the beach. Yeah, I'm trying to figure out if I can. If I can show my screen and then still see when people need to hop on. I'm going to try that. See if it'll let me do that. I didn't know that I wouldn't be able to see that. Where did it go? All right. You guys see that, right? Yes. Present. Okay. So weird, because now I can't. I can't see, like, when people want to be admitted on. So that's a problem. I guess I gotta hang out a little longer. Not gonna work. Oh, wait, More chat. Hmm. Okay. Yeah, I can't see all the people that want to come on when I'm sharing my screen. Okay, that's okay. You guys keep telling me where you're from and what you're gonna do for fun when you have more time and.

What you're using.

Now. I'm. I'll introduce myself and stuff in a few minutes. Once we feel like everybody's hopped on, we're beaching. Oh, you guys are hot. How hot is it in Arizona? Bridget, this is emr.

Pumpkin Stitching.

Office Ally Craft Speech. Ooh, Going to New Zealand, Kristen. That sounds really cool. 106. Yeah, that's hot. Hey, a paper only. Guess what Paper is my favorite. But I. I set this up so for non paper people. But paper is my favorite. I still do Paper Seattle. Nice, Kylie. All about. Ooh, another paper person. I think the EMRs are a lot of. What are Time suckers? They make it harder. I think a lot of the time we saw the ones I've been on. Okay, well, I want to start, but I don't want to miss people that are trying to get on. So I guess I'll. Maybe I'll just start my introduction without showing the slides yet. That will give it a couple more minutes to let people in. Hold on. More people popping on. Okay, so if you haven't yet, say where you're from, what you're going to do for fun when you have more time and what you're using right now, like for an emr or if you're using paper like me. But don't worry, I'm gonna. I'm making this for EMRs. Okay. Okay. So I'm just Gonna start talking and then I'll show. I'll share my screen after. I feel like people are all on. It's 5:06, so people are still hopping on. So. Okay, so tonight what we're gonna do is I'm super excited to help you all. I have you guys go ahead and everybody mute yourselves so that we don't get all that background noise. I'm hearing. I'm hearing some background noise. So make sure everybody's muted. And then Morgan, if you see anybody not muted, could you please send them like, like a little message to let them know. And so what we'll do is I'll do little just welcome present introduction. So those of you that don't know me know a little bit about me. And then I have a PowerPoint presentation that apparently when I'm in that mode of screen share, I can't see when people need to come on. So that's why I'm kind of holding out a little bit. Make sure everybody's on. And then towards the end, I'm going to share something special that I'm doing that's just available to a few people if they're interested. So I'm going to just share that with you and then I'm going to do answer your question. So the way it works is Morgan Smith here. She's my. Hey, she's been promoted. She's my administrative assistant now and still helps me as an OTA too. But she's super awesome and she's going to be paying attention to your questions and any questions that she can answer for me along the way while I'm talking, she's going to answer. But then she's going to collect the ones that I need to answer and then I'll answer them at the end. So she's going to organize all that for me. And that works really well. Yeah, and that's about it. Well, I'm afraid to start because I feel like somebody might not get on, but it's 508 thumbs up. Should I just go for it? If you're not on yet, you'll have to watch the replay, I guess. Okay. All right. Looks like everybody's on it. Slowing down. Okay, share screen. I have to get myself organized here. Get that over there. All right, can you all see that picture? Oh, wait, I gotta go to presentation mode here. What happened? I promise you I was very organized and ready for this. But what is going on here? Okay, got it. Okay, so here's the beginning of the presentation and we already talked about. I'm excited to help you. And you. You guys are typing in where you're from. Daily note, what you're using for daily notes and what you can do. Have more fun. And I told you what we're going to talk about. And so here's just a little introduction. I'm Mary Koska, and this is my honey, Pete Koska. And nobody accomplishes what I accomplished without somebody to keep me from going crazy. So Pete is my wind beneath my wings. Hmm.

We can't see the slides. It's just black.

It's black.

Yeah. Nobody can see it.

Weird. Okay, hang on. I can't see anything either. All right, thanks for telling me. Hold on. Maybe I didn't click on the right thing. Can you see it now?

Mm.

Okay. I must have clicked on the wrong thing. Okay, so that's my honey right there. That's Pete. And then these are my boys, my dogs, My mom. My mom and I went to. Went on a Caribbean cruise. And this is my clinic. Some of my people, my clinic. This is my first client, Reni. I started my practice 11 years ago. I own Ohana Occupational Therapy. This is my awesome staff, one of our awesome kids. So I have a private clinic, and I like to have a lot of fun. I do not like to spend one extra minute doing any documentation. So I am excited to share with you how I do that. And this is what we're going to cover. Reasons why we over document my seven essential components, examples of some documentation, and you're going to make yourself a little daily checklist. So make sure you have something to take some notes. This is. This should be recording. I set it to automatically record, but can you guys see anything that says it's recording? Yeah. Okay. Because I'm not seeing anything on mine. Good. So I will send you the replay. So if you don't want to go crazy taking notes, you're going to get to see this again. And I think I'll just send you the PDF so you can just see it that way. I think that'll be nice. You can always screenshot, too. So my seven essential components, examples of documentation, daily checklist, and the recap and the Q and A. So wishing for the. Are we doing okay, Morgan? You guys can see me, hear me? Everything's good. Okay. All right. Wishing for the Holy Grail. So, you know, I worked. I'm 32 years into my. Into being an OT. Well, September will be 32 years, so I guess I'm about at 32 years. So I've had about a total of maybe seven, no, six years doing rehab, like medical models. 17 years in the schools, couple years doing home visits, birth to three, 11 in my own private practice. And I can remember about 20 years into my career when I was working for the Bertha 3 Center, sitting there at my desk wishing for the Holy Grail. I'm like, I'm 20 years into my career and there's nothing to tell me. No one to tell me that my note is good enough, that it's not too long, it's not too short, it has what it needs in it. And I'm like, why I need that? I need somebody. And part of it is like, most of my bosses weren't even OTs, so they have no clue. And I would buy books on soap notes and all this stuff. And it was just like nothing really solid to guide me with what I needed to document. So I just remember just sitting there wishing for the Holy Grail. Now, I'm not going to say I really have the Holy Grail, but somebody did call. What I'm doing is the Holy Grail. So it's just what I'm doing. It's just what I figured out. So I'm just sharing what I'm doing. But it's really what I make sure is in every note. And I feel good about it. And I've had it scrutinized and it's all been fine. So I just share with you what I've learned. But I think what's really important to go over. Because I can tell you all this stuff and most of you won't do it because you'll feel naked. You'll feel like there's not enough in my note. Then you'll just write a book, even though I showed you how to do it short. So you have to think about what you know, what you're afraid of, really. So I'm going to tell you everything that I was afraid of. So, you know, fear of being audited, not sounding professional, not a fear of not being understood. You know, feeling like I had to explain everything. Educating a lot, advocating for OT in my note. Fear of my service not being covered. Fear of them taking money back. And they do do that. They take money back. Sometimes fear of missing something, like something important is not in there. I didn't have a framework or a structure. Fear that I was lacking information. I had. I have this problem anyway, being concise. I've never been a very concise person, to the point person. I can be really wordy anyway, so it's just like not my I'm just not very good at that. And then lack of education on how to show clinical reasoning or skilled services in a brief manner like nobody really ever told me, like, how do I show that this is a skilled service but not write a book? Perfectionism. And I just really, you know, we all want to feel like we did a good job. And then I think this is the biggest one, wanting to include everything that I did because it was all so awesome and amazing, play by play. And so for all those reasons, I was too wordy in my documentation. So I'm guilty of all of those. So now how I got here is that I do not have good memory skills. And that has been something that's made me, over my career, create a lot of systems. I like checklists. I don't like having to think of words. I don't get paid. You know, I'm trying to survive as a private practice. I can't, you know, I can't. And anytime that's not at work, I'm often working on my practice. So, you know, there's no way I can be spending tons of time documenting and evals is a whole other thing. But you know, I would write these like 20 page evals, ridiculous thing and now I write them in 15 minutes. So between me having poor memory skills that I'm in private practice. So that kind of forces me to be efficient, be efficient or my practice dies and I can't help anybody. So now notes are always done in session. None of my staff stay late. None of my staff bring any paperwork home. Zero. In fact, when I shared with them what everybody else was doing in my survey I did, they were pretty shocked. They can't fathom it. Although one could because she used to do two hours every night so she could remember what it was like before. I had a mentor that, that for 10 years that he was an expert witness. He's PT. And I learned some really interesting, like little things from him about things that he said people would write volumes but they wouldn't include the most important things. And so I learned a lot about like things that need to be in the note from him. So that was pretty cool. And then I use a flow sheet. It's mostly checkboxes with places for data, places to write the plan and what the parent said, but it's mostly checkboxes. And I use an activity log with what I'm going to share with you today. You'll still want to have like some kind of activity log to make this work, but I can send you Guys, you know, if anybody wants it, my paper checklist. But the reason why I prefer paper is because I work with kids, they're distracted by electronics, and I can't just throw it on the floor, work with the kid and then jot something down. And work with the kid and then jot something down. They don't care about my file, and it's just easier for me to do it in the session. I know a lot of people are really successful doing them in session with, like an iPad. And so I think that this is possible that way. But regardless, what I'm going to show, you can be done in like three minutes. So even if you have to do it like after your child's done and you have that, those few minutes to document on your computer, it's still going to save you a lot of time. Having a structure, I think saves a lot of time. But that's why I. I mean, I studied emrs for so many years because I kept thinking that I have one for my. To operate my business, but I just don't use it for documentation. But that's why I like paper. It's faster and the kids aren't distracted by it. So here's the seven essential components. Are we doing good so far? Everybody doing all right? Yep. Okay, there's. And I'm gonna go into these each in detail, but this is just the overview. You have to have certain things in your demographics. So I'm going to go over that. The subjective. I call it the golden nugget. And I'm going to go into detail about that. But I'd much rather talk about something that reflects their progress in the subjective. And I'll explain that a little more. I like to focus on two goals at a time. We'll talk about how it needs to be measurable in the objective part in 4 and 5. In assessment, there needs to be something that talks about the medical necessity and about their progress and their compliance. And these, these are things that are often missing that people don't put in there. And this is often. Also what is missing is a lot of people will just say, continue plan of care or something like that. This is your opportunity to talk about what you're going to do different and why it's skilled. So we'll go into details there. And I usually. I'll say upgrade or downgrade, and then I'll talk about what I'm going to do and then making sure your note is signed and dated, which with EMRs, it's pretty automatic. So. But that's just something that sometimes comes up. So here's the things you need to have a lot of. It's just pretty obvious. Your data session, your start time, the total session time is really important. It's more important than putting in like the end time on a paper note. It's almost better to not put the end time because what if you calculate it wrong? You know, the important thing they want to know is the total session time, the procedure code, the name of it and what you're doing it for. And I'll give examples of these in the order the procedures were done. And I have this, this general statement in my notes that you'll see where I put it. But it's just kind of a catch all. Unless otherwise noted, all time based procedure modality durations follow what's outlined in the CPT and includes verbal, visual, tactile cues or corrective assistance. And the reason that's in there is if I forget to say something about that they needed a certain amount of assistance. This is showing that it's skilled that I had to provide something and then also that I'm following the guidelines for like the eight minute rule and all that. Remember, if you have questions, type them in. And Morgan's gonna take those. I gotta shrink you guys because I can't see my slide. Okay, so session demographics. So here's an example how it would look in a narrative. Esther sample that I just did that for. Last name, date of birth was seen on and then the date for a total of 60 minutes of OT services, 4 units therapeutic activity. Then put the number in 97530. And then this is where you want to say what it's for. In her case it was to address cooperative play skills, respiration. And then we also did one unit of the feeding to address exploring new foods to decrease restrictive eating. So here's the golden nugget part. So you want to talk about changes in condition and subjective. And I like to focus on the positive about something that's been improved and be clear to state that they're better. And if they're not, if they're the same or worse, you want to say why. For an example, mom stated se8 and new food, half a tortilla for the first time, she's better. It's very clearly stated that she's better. And then okay, so here's the thing. Like parents come in and they've had a rough time. The kid just had a huge meltdown and they're like, you know, they're just really. They're not saying anything positive because they're overwhelmed. So in a case like that, say they said, like, they just had the hugest meltdown, or we had the roughest weekend and they're telling you about it and then you're thinking to yourself, it's been a while since they've said that. And then I would flip it around. And staying in the subjective, child had a huge meltdown this weekend. I'm going to say I'm going to dig until I figure out what's positive. And then I'll say, it's been a while. How long has it been since he's had one like that? And then they'll be like, oh, yeah, it has been. It's been like a month. Well, that's what I'm going to write in my note is that it's been a month since they've had a huge meltdown, because that's the positive part. So I'm really good at taking anything that's negative and then figuring out what's positive about it.

And.

And that's how I want to state it in the positive. And if they're not better, you know, they've been sick or whatever, you just say what's going on. Another thing that I have is that I have, like, I find that if parents are just really overwhelmed and negative, they need to dump it out before they can get to the positive. So I have like. And I also don't want them to say it all in front of the child, but I want to know about it. So I have a form for them to fill out that they can fill out. They can tell me what's going on. And then after all that, then it's asking them what's better. And then they can usually come up with something. But my job is to find that golden nugget. And the other reason is that when you set up the expectation that you want to hear something positive when they come in, it just sets up a positive cycle that I have. One parent that comes in with a page of positivity. I can't wait to tell you all this stuff. And she documents it, every little cool thing that her kid did, and it's great. So for hers, I have to say, see attached note because she writes a book, okay, so objective, Measurable change and two functional goals. So one of the problems, one of the reasons that our notes can get really, really long is that we're trying to address, like, every single goal we have in every session and documented on it all. That's actually a really Inefficient way to help kids. And when I first learned this from my mentor, I was just like, but we're pediatric OTs and we do this and this and this and this. And there's no way I'm going to focus on just two goals. But this actually works really, really well. So what I do is I focus on two goal areas for at least four sessions in a row. It doesn't mean I don't do other stuff, but this is all I document on in my notebook. Everything else would just be like a check off on an activity list, which I'll get to. But if I ever had to go back to like, what's all the other stuff you did? It's there. But in my note, I'm only focused on two measurable areas for at least four sessions. So you always want to have, try to have a number in here. So percentage, seconds, minutes. You can have type of assist, you know, like just like how you do in a rehab note, like mid mod, max assist. However, you might be stuck at mod for a long time because mod assist is what, 50% to 75%? Well, they might have made a lot of progress. You keep saying mod, mod, mod. So it's better to say, you know, 50% assist, physical assistance and now it's, you know, and then, or you know, maybe they were 75% physical assist and now they're 70 and now they're 65 to actually show progress. You want your note. This is really important to be so obvious that how they're doing that anybody could pick it up and read it and know this person improved. Okay. Because the people that are reading it, not therapists. My mentor had a nephew that worked for an insurance company and he kept saying, remember my nephew's reading this, he's like, he's a high school education and that's it. So, and then you want to number, you want to make sure there's something in there that kind of is showing the order of the treatments provided. And that's just to show if you're using more than one code that they're separate interventions or whatever. So here's an example. And here I said minimal instead of a percentage. It would have been better if I said a percentage, but minimal verbal cues to chew a cheese tortilla all the way. 75% cooperative play with brother during a game. 5 minutes respiration activities without fatigue with blowing activities. And then I kind of gave an example. You don't have to say what it is, but that was just more side Remember dragon breathing. And then for the assessment part of the note, you want to make sure that you say something that it's medically necessary. If you're in schools, I don't know that you really have to say it's educationally necessary still, but it wouldn't hurt. And then if it's not, you need to say why, but you need to think about that every time because that's what they're looking at. So sometimes I just say it because I've already said how it's medically necessary in my eval. But you could say more than just treatments are still medically necessary. But at a minimum you need to at least say that. And then you also need to say oh, you also need to say something about their progress and their compliance that's just very clear. So something as simple as clients progress is on track. As expected. Compliance is good for therapy and home program. And if it's not, you need to say why. This is the kind of stuff they're paying attention to the most. They're always wanting to know have you given a home program? Are they compliant with it? Are they participating? Well, that sort of thing. Okay, so then this is another really important part on the plan. Remember I said don't just say like plan of care, continue plan of care you really need. This is where the cool part is, where you're going to show your thinking, your clinical reasoning, the skill part of what you do, what are you going to do different? And we do this all the time, we just don't spell it out. So these are some examples. So you might upgrade it. So increase to three piece obstacle course since they're doing so well, ready for more rotation, ready for more stimulation tolerated. Ils well so can go to the next level ready for increased period interaction. Those are just a bunch of examples. It's just as skilled to downgrade the activity. You know they're overstimulated or they need more structure. So like needs more structure since overwhelmed. We're going to do a picture schedule next time. Even like when you're downgrading to doing first. Then if you're having to make sure they have a visual timer. A lot of our kids we have to downgrade to making sure the lights are off or there's not a bunch of stuff in the room or they're going to need more hands on, more physical support or maybe we need to lower swings so that they're not as fearful. These are all skilled things. These are the things that just not the average person would know to do. And so you have to spell it out a little bit. All right. I know this sounds sort of silly. Signature and date signed. But the most problems that I have with notes are stupid things like this. So since I use paper, if I do get notes requested, I'll just take my paper note and I don't want them to say, well, I can't read it. So I just take a few minutes and type it into a paragraph like I showed you and I just put it on letterhead. Well, the dates at the top and I signed it at the bottom. But guess what? It didn't count because they didn't have a date next to my signature and that was the only reason that they didn't want to pay. So I had to redo it and put my date next to my signature. Even though the date was at the top of the note. It didn't matter. So here's an example of what that whole note would look like. So it's just everything together. So Esther, date of birth was seen on 4162020 for a total of 60 minutes for occupational therapy services. 4 units of therapeutic activity 97530 to address cooperative play skills respiration 1 unit of 92526 feeding to address exploring new foods to decrease restrictive eating. Mom stated as he ate a new food half tortilla for the first time she's better. Minimal verbal cues to choose tortilla all the way. 75% cooperative play with brother during a game 5 minutes respiration activities without fatigue with blowing activities I.e. dragon breathing treatments are still medically necessary. Clients progress on track as expected. Improving compliance is good with therapy and home program Upgrade activity to include more cooperation with pure play and increase respiration endurance and explore a new food. And I said well we're going to try avocado and then that's and then at the bottom is when I put the Unless otherwise noted all time based procedure modalities. Durations follow what's outlined in CPT and include verbal cues, visual cues, tactical cues. Corrective assistance. Services were provided in the order this is where I take care of that order thing. Services were provided in the order listed in the note unless otherwise stated, signed and dated. So here is an example of what that might like look like for a school note. So kind of the same thing. Their name, the date, blah blah blah. Total of 30 minutes for OT services 2 units of therapeutic activity 97530 to address fine motor and visual motor skills. His teacher stated that he's less frustrated and participating more in handwriting in class he's better able to imitate a diagonal line for the first time with 25% verbal assist. Able to hold pencil with fingertips and tripod grasp for 1 minute after 10 minutes of fine motor preparatory resistive activities to facilitate muscles in fingers. See how that sounds? More skilled treatments are still educationally necessary. Students progress on track as expected. Improving compliance is good with therapy and there's carryover in the classroom. And then I said for my upgrade I'm going to try to increase the amount of time that he's able to hold hold it in a tripod and try to decrease the verbal cues to imitate the diagonal line so the rest is the same. And then I made another example here that's this is kind of more a lot of what my notes look are a lot of self regulation, being able to be still, sit still. So Sally's sample date of birth was seen on 4162020 for a total of 60 minutes for OT services. 4 units of therapeutic activity 97530 to address self regulation, core strength and attention. Mom stated that Sally is now able to sit in a chair at dinner for five minutes three times this week. Also no meltdowns this week she's better core extension Superman 22nd sat for a tabletop activity for 10 minutes after 20 minutes of preparatory gross motor activity to facilitate the core muscle activation. Was able to demonstrate an activity to calm self. Five finger breathing one time with moderate visual and verbal cues. And I could have used a number there and then the rest is the same. I kind of have my canned statement. It's better to not use canned statements, but as long as it gets this gist across, treatments are still medically necessary clients. Progress is on track. As expected. Improving compliance is good with therapy and home program. And here I'm going to upgrade activity to include less visual and verbal assist with the breathing technique. We're going to do a five piece obstacle course to activate core before increasing the sit time with the tabletop activity. And then the same little spiel at the bottom. And then this is really important because I think one of the reasons that we over document is because we have in our head we've heard, well if you didn't document it, it didn't happen. Who's heard that before? So then you end up, you know, holy tamoly. If I wrote down everything I did, you know, when I have a student and I'm articulating all my thoughts and everything, I'm like holy cow, I could write a book on every session. There's so much going on. So we have a really simple activity log and it's just, it's just a grid and it's just the activities and you just kind of check off that they did them in the date, everything that we did. And then it's really nice because if somebody else is covering me, I have all the different pieces of equipment we use in obstacle courses on there. I have different things like zones activities or the ILS or different fine motor things. So what's nice is if one of my codas picks up my chart or I pick up one of theirs and we open it up. At a glance I see a whole bunch of check marks by the spandex. I'm like, oh, I know I can start with that one. We use a code, like a plus means it went well, it was just right reason, like an up arrow or just a line, like a pointy thing. I can't think of what you call that, like the top half of a triangle to say like that they were over responsive to it or under responsive to it. Mostly they're all pluses because we're getting them in the just right challenge. But I can open it up and I can see all these pluses on things. I'm like, ooh, I'm starting there. I know that's what they're used to doing and it's good. I can look on there and go, oh my gosh, they've never done the helicopter and they're looking bored. I'm going to try that today. So it's. You need something like at a glance where you don't have to read through a bunch of notes to know what you've done and what's went well. So if I ever needed to document more about a session for any reason, I could pull that off my activity log. And if you're in an emr, you just upload it and add it to the file. You can have like, gosh, ours, I think cover three months worth of dates probably. So, you know, it's nice, you can see a lot on there. So here is what I suggest you put in your checklist. You could screenshot it if you want, or write it down. But make sure you have in your demographics, this date, the start time, the total time, the codes, what for, and something about the order. Like my little spiel I did make sure you're in your subjective, that you're trying to focus on the positive, pulling that golden nugget out, like to just, you know, it takes a little bit of work sometimes. My parents don't think of it till like halfway through the session. And then they're like, oh, they did this this week. But they know I'm expecting to hear something. So I always usually will get to hear something good. But if it's not going well, you can, you know, you can say why. And like, you know, parents still struggling will increase. We'll give them some new new home program ideas or something like that. And then you want to make sure you're objective, that you've got measurable change and two functional goals. And again, assessment, medical necessity, statement about progress and compliance. And in your plan, you want to make sure you're talking about something that will be different. That's your skilled part of it. And I like to just kind of focus on upgrade or downgrade. Makes it easy for me to think about, like how I'm. My clinical reasoning usually falls into upgrade or downgrade, signature and signed. And then this is just kind of a little bonus thing. Words that show skilled care. So verbal cues, tactile cues, physical assist. When in doubt, write it kind of like you did in rehab. That's really what the note needs to be like to show the skilled part. Upgraded, downgraded, facilitated, guided client for correct, whatever. Updated, modified, adapted, assessed, engaged, caregiver, stabilized. You know, talking about preparatory, a lot of what we do, the way we make progress is because we're doing all this preparatory stuff to either calm them down or to facilitate the muscles so that they can do something. I think that's really important to mention. And then your observations of, you know, their fatigue, stress, anxiety, aggression, you know, talking about compensatory strategies. Here's some don'ts. I think sometimes it's easy to just. Unless you know your EMR won't let you do it. But like, when you're handwriting notes, a lot of times it's really easy to leave off a year. Don't forget to put the whole, whole year in there. We talked about the date next to signature already. This is important. I'll talk about the coaching a little later. But like, I'm getting into seeing, like how people are writing their notes and sometimes I read them and I'm not seeing anything that makes it sound skilled because I'm seeing just words like coach to, you know, teach and coach. It doesn't sound like a therapist did it. And then give too much. This is where we all kind of fall into a trap. Give too much. Don't give too much detail of every single activity. Put that in your activity log. You can just say three Step cutting project. You don't have to say they made an octopus and we put this on it and that on it and glitter or whatever. You don't have to put all the details in. You don't need to write a play by play of the whole session. The activity log covers that. And don't forget, don't leave out numbers. You need to have some numbers in there because then you know you're providing measurable data there. This is surprisingly easy to get off track that people sometimes get off track and they're not focused on the actual goals that you wrote. So that's why I say two goals that you're tracking and don't lack clarity on if they're actually making progress. And then of course if they're not, say what you're going to do different. So they will just stating things like tolerated well isn't useful. Repetitive language. Just saying observing isn't really sounding skilled. Encouraged, supervising. These aren't very skilled things like anybody could do that. And then we talked about don't just say plan of care. Let's see. I just want to make sure I didn't skip something. Okay, so back to what we do want. So we do want session demographics. The golden nugget. Measurable change in two functional goals. Medical necessity. Statement about progress and compliance. Something about upgrade, downgrade or what's going to be different. Signed and dated. And then that is basically it. So one thing that's really helpful is put in the chat and I can look at it later but let me know if this was helpful and if it was. Why? Because I think it's helpful. But unless you tell me, you know, I don't know if it was, you know, if there were some things that you hadn't thought about or if it made you think like, yeah, okay, I don't need to put all this in my note, but I can focus on this. You know, let me know if this was helpful. And, and then this is when I was talking about something special that I have. If you need one on one help with your notes and you want more time back, I have. I'm inviting you to apply for a one on one six week coaching program. And this is where you and I can work together to streamline your documentation to get hours back in your week. So I'm only doing this a total of maybe five people. I have a couple already so I'll take maybe three or four more and that's it because I have, because I'm running a practice and you know, treating kids and Everything. So but for people that are just like, just in deep and they can't find their way out and they need somebody to help them, like I'm literally holding hands in their EMR with them. We're sharing screens, we're rewriting stuff, like totally helping them see, like, okay, well this makes sense. But you don't need this in there. Just helping step by step by step. And so I have an. And it has to be somebody I really think that I can really help. And so if you're interested in applying, you just go to this link here. Bit ly and then my name and. And Morgan, can you type that in the comments too? That link? That would be helpful. So it's just something special I'm doing and actually how I started doing it is because somebody asked me to do it for them. They just really needed help a lot. I mean, I'm talking to people that are like passing out on the floor of their clinic at the end of the day because they're so exhausted or they're writing notes like at midnight. And I've had people like message me at like 11 or 12 o' clock at night. And like, yeah, I'm documenting right now and I need help. And so it's just something I'm doing for a few people that really need some extra help. And now for question and answer time. So I'm going to stop sharing so that I can see everybody. Oh, wait a minute. There's some people that didn't get in. I feel bad. A couple three. All right, so let's get some questions and answers. And to those three that didn't get in, when I was sharing my power, when I was sharing my screen, it would not allow me to see who else needed in. So we waited about, I don't know how long. We waited almost 10 minutes to try to get everybody in. But everybody will get a replay. I apologize for those three people that didn't get in before I started. So Morgan, do you want to unmute yourself and tell me what the questions were?

So most of them just came right now at the end. So I'm just going to read them.

Out of the chat.

Okay, so one of them is, do you have to consistently measure the prep time of each session? If you measure it this session, should it be included in the next session?

Did you say the prep time? Yeah. Are you talking about like doing like gross motor preparatory activities? Is that what you think they meant?

Hey, Mary, can I ask that? I figured it might be easier. Yeah. So you mentioned that you say 20 minutes of like gross motor preparatory. Do you have to measure that consistently the next session as well, like to show progress or improvement?

Well, that's not, that wasn't a goal. That was just something that I just, I just put in there. So now it doesn't matter.

Okay, thank you.

Unless it's a goal. I mean, you have to put that in there like an amount of time or anything, right? That was just an example because sometimes I think, you know, people don't really realize what takes time, you know.

Well, and that was the question. If you put that time, is that a red flag for consistency and improvement? Like would they be looking at the next note to see it only took 15 minutes or 10 minutes?

I don't think so.

Thank you.

No. And you don't even have to. I mean, unless it's a goal, you don't have to even put a time. But I just, I just use that as an example, you know. Thanks. The main thing is. Sorry, I'm trying to figure out how to get my people. Sorry, I'm just trying to navigate this thing. Okay. The main thing is to be focused. And the thing is you want your documentation to be a tool to help you actually help the child. And I think that what happens is our documentation becomes this nightmare that doesn't help us help the child. And so when you focus in on a couple of goals consistently, at least for a few weeks, then you start to actually really make some change. But I should also say that like in my chart I have like all the goals listed and periodically I'll go in and give them credit, you know, like, wow, they sat for 15 minutes. That might not been one of the two that I was tracking, but I'll still go in and give them credit, you know, or that they followed a multi step direction. I mean, I'm always looking at the full list of goals and then I give them credit in my data. It's just that what am I going to put in the note? I'm just consistently tracking a couple things at a time and that keeps me from writing too much.

Another question is, do you need to align language to state MA language?

Say that again.

Do you need to align language to state MA language?

I guess I don't understand the question to somebody who wrote it.

What I'm asking is, do you have to align your language in your notes with the state medical access language that they use? Have you found a need to do that in order to defend yourself in any way?

The state medical. What state are you in?

Pennsylvania. So when we bill for medical access, we're given options of the activity levels that are the activities we've done and are using visual, motor, are you using sensory regulation? Are you using in hand coordination? Do you have to get that detailed?

Oh, you know, as far as I know, I don't have that. I haven't run into that. So is this for like Medicaid?

Yes.

Not private insurance?

Not school based?

School based. Since I'm not familiar with that specifically, I'm not sure I can answer it. But what I would do is are you. Do your goals have to be aligned with it?

Yeah, you usually. Well, based off your eval.

Right.

And then you're writing what the needs are and then developing your goals. But when we document, we have to kind of put them in. It really is like a drop down of what you addressed in the session. And your language is supposed to kind of parallel it. It has always been my understanding in 27 years of doing that it makes sense.

I mean if you, if you said if you had a self regulation goal or a visual motor goal and then that's what you're documenting on, you would use that language. I mean that just seems logical to me. Me.

Okay, thanks.

Yeah, you could send me an example and I could look at it. Okay, thank you.

So the next question is, how do you document sensory. Do you write the words auditory, vestibular, tactile or avoid them?

Oh, that is such a good question. I'll tell you what I do. I focus on function totally. And here's what I do for my goals. So all right.

For me.

The underlying critical things that need to be in place are reflexes, core prop, vestibular, tactile. Like all these things that need to be in place. They don't care about any of that stuff. So I track it for myself so that I know that I'm on track. But my goal about that stuff is super general. It's. Oh gosh, I'm trying to think of the wording, how I say it. I might have to pull it up to tell you exactly how I say it. But it's basically I.