Whose story does your therapy documentation tell?

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Renee Kinder
Renee Kinder

In 2012, I sat with my eldest daughter and family in a banquet hall watching my mother receive an award for her career in journalism.

Correction, rural journalism and, yes, there is a difference.

She talked about how reporting in your hometown means you occasionally wade around in your own history. And it's messy. It is sometimes lonely because you have to write unflattering things about people you know — about your own people even. You have to be careful with friendships, and you have to tell the truth. And then you see the subjects of your stories in the toilet paper aisle at Kroger.

Then she said something that made it all make sense to me.

She said, “If you don't do good journalism at small papers then you are telling people who live in rural areas that their place in life, in the world, is not that important.”

It justified all the up at 5 mornings before school I endured as a child sitting in the courthouse offices while she completed the crime roundup, every weekend reading books and coloring at a desk in the newsroom when she was on deadline, and every single small town community event my brother and I attended at her side.

Her statement also made me think about how we as therapist document.

Therapy documentation should tell a story.

So, I ask, “What story does your therapy documentation tell?”

We know according to regulatory standards the documentation must tell a story of skill, of the unique needs for a person to receive care at the hands of therapist, and that the care must be complex and sophisticated in nature.

However, in the spirit of culture change and the movement from patient care to person centered care, have we considered what story our documentation tells about the person themselves?

Does Mr. Jones need to “ambulate 50 feet with a rolling walker Independently with adequate stride length”? Or should our goal targets reflect what is important to Mr. Jones tied to his ability to ambulate: “Mr. Jones will demonstrate his desired ability to ambulate 50 feet with a rolling walker Independently across uneven surfaces with adequate stride length to allow for his ability to attend community events with his family.”

But first steps first. To tell a patient's story in our documentation, we must first know their story and this begins with how we complete our therapy evaluations and collect baseline data.

I consider a case from my own past. I recall an individual whose goal was to return to the community and engagement with his large family. Weekends were structured around the grandchildren, their sporting activities, and eating — lots and lots of delicious home cooked meals in addition to dining in community restaurants.

The later setting had gradually led to stress, anxiety and eventual avoidance due to difficulty swallowing and the fear of choking in public.

His Prior Level of Function was not merely, “Independent Swallow”.

His Prior Level of Function was, “Independent Swallowing ability in group setting while engaging in communication and interaction with loved ones.”

What I learned from this grandfather, who was strong and beloved by this family, was that greater than his individual fear was the potential stress and impact on his children and grandchildren seeing Grandpa choke. His resolve was simply not to eat in restaurants. Our treatment plan had to show what was important to him and his family.

Treatment for this individual was based not around the “ability to swallow regular textures without overt s/s aspiration 100% of the time while maintaining adequate nutrition and hydration.”

Treatment was based around his goal, to consume desired level of oral intake without instance of choking or sensation of pharyngeal residues 100% of the time, while eating with loved ones and engaging in conversations. Treatment mirrored this goal and included the skilled complex care aimed at improving the swallow in addition to the important aspect of dining with family and actively using appropriate swallow techniques to enjoy a meal once again.

In closing, I must say, “Thanks, Mom.”

Thanks for showing me that everyone, regardless of how we come to interact with them in life or as therapists, has a story, no matter how big or small, and sometimes we can be the ones to put in writing the words that show they are important after all.

Renee Kinder, MS, CCC-SLP, RAC-CT is Director of Clinical Education for Encore Rehabilitation.  Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association's (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association's Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).


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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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