Ending the Burden of Documentation

When I first started as a physical therapist, we were using paper documentation. There were plenty of days the muscles in my hands would be cramping because of the amount of time I’d spent writing about my patients’ sessions. I’d also be in a hurry writing, because I really didn’t want to have to document.

I remember telling myself that the documentation is important, not just for insurance purposes, but so that I remember what is going on with the patient for the next time that I see them. I actually still believe that, and in many ways this is the most beneficial part of documentation. I simply can’t remember everything I do, but if I write it down, I’ll be able to review it in the future.

Fast forward a decade and I doubt you can find a healthcare setting where electronic medical records aren’t being used. With the electronic format, documentation seems to be constantly changing, and it often felt like more tasks were being added to the already detailed and extensive documentation requirements.

In my job at a local in-patient rehab hospital, I vividly remember spending many evenings silently cursing insurance companies, hospital policy, and my never ending documentation items that kept me at work late and away from my family and hobbies. In many ways, I cursed it for getting in the way of my life.

Then recently, I began to notice how I was casually finishing my documentation without the continuous river of curse words running through my head. I was finishing them in what felt like nearly half the amount of time, and getting home to my family with time to cook dinner, work out, play outside and enjoy my life.

To be entirely honest, it was weird.

I was genuinely confused by the shift, at least initially.

Since the requirements for the documentation didn’t change, the only thing explanation was that I no longer felt overwhelmed by it. The reason I no longer felt overwhelmed by it, was actually quite simple.

I stopped thinking about all the documentation I had to to, and simply wrote the notes.

That’s it. I just simply did what needed to be done. But there was immense freedom that came with this shift. Freedom to show up, do my work, go home, and live my life. Without the heaviness of the consistent stream of thoughts I had been carrying around for so long, documentation no longer looked like this 20 foot hurdle that I somehow needed to jump over in a single leap.

What if you could see the non clinical requirements of your job with a fresh look? Meaning, all the things that you have to do every day that have no direct impact on your interaction with patients, but are still required for your job. Because when we aren’t carrying these things around with us all day, they aren’t in the room with you when you are talking with your patient. You aren’t carrying them with you when you go home at the end of your day and the energy it saves you is worth its weight in gold.

If this sounds intriguing or resonates with you, I’d love to invite you to a conversation. We can explore how this might change things in your life and in your work.

Much love, 

KC

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