If you had emergency surgery overnight and couldn’t go back to work for several weeks, would another clinician be able to look at your notes and pick up where you left off? Will they read your goals/objectives and know exactly what you were planning to address? If someone had to update your goals and objectives for you, would they be able to do so by looking at your notes?
As much as we are data driven, we don’t always take the best data. Yes, we take some sort of data but how thorough is it? We have the date, time, and activity we did when we saw our client/student but what did you write after that?
Public school SLPs are normally back to back with students. We write down what we did with our students or why they weren’t seen and have the best intentions to go back to our notes and write down what actually happened in therapy, but we don’t. Who plans ahead and thinks of the “what ifs?” I didn’t, but I do now.
I had a health problem last year and went on leave for the remainder of the school year. I was pissed because I had heard awful things said about me. Why? I’m a good clinician and I work well with my colleagues and students. I didn’t leave enough data for my temporary replacement. I thought “they” were nuts when I heard this and spent several months reassuring myself that I did nothing wrong.
Karma has a way of finding you. She found me twice this school year. The SLPs I replaced left me valuable information about my new students, campuses, procedures, etc… . I thought I had it so easy. It was easy until I had to update goals and objectives. There were notes about what activity was done and what objective was targeted but no information regarding student performance. I updated the information the best I could with the information I had. At first I thought my OCD had kicked in and that I was making a bigger deal out of the situation than it really was; however, when I discussed it with a couple of my colleagues, I learned that they didn’t always document student performance either. We all thought about this and played the “what if” game. If someone would have to update goals and objectives for us they wouldn’t be able to provide the data. Sure, we know our students pretty well and have a good estimation of where they’re functioning. Knowing and proving it are two different things. We should have our documentation organized in such a way that anyone can look at it and know exactly how a student is progressing. Attendance sheets and stating what objective was targeted is helpful but simply not enough.
This experience has given me another perspective in how my colleagues and I document student progress. We need to look ahead and plan for “what if” because one day the “what if” just may come true.