Two questions to improve documentation
There’s a powerful question that many of us use with clients: “What is your experience of XYZ?” It moves away from the facts, and into the realms of what is important to the individual and what self-beliefs are influencing their recovery.
Using this question with direct service staff can have equally powerful results. Let me give you an example.
In documentation training recently, I showed staff (case managers, rehabilitation staff, ACT team members, and clinicians) brief vignettes of real clients and then asked them to document what they saw. Before discussing their documentation, I asked them to respond to “What was that experience like for you? What did you observe about your experience of watching that client and then documenting what you saw?”
I was expecting short debriefings before we moved onto the main event – what they actually wrote. What happened instead became the main event.
Time after time, with six different groups of participants, the answers were personal and compelling:
- “I found myself wanting to describe his illness, and having a hard time seeing him.”
- “I kept bouncing between seeing this person and getting stuck in all the symptoms.”
- “It was hard for me to find words that weren’t straight out of a text book.”
- “The pull of judgment is so strong – it was really hard to just observe and describe.”
- “I could either be proud of what she was accomplishing or describe her mental illness – it was difficult to see both at the same time. Kind of like those optical illusions.”
Having an opportunity to identify their personal responses and experiences, made it easier for the participants to move to a more descriptive documentation approach. They could begin to separate out their own biases, set them aside, and simply report what was happening. Their resulting documentation became clearer, more individualized, and more strengths based.
In another exercise, I asked participants to watch a video vignette, then to document what they saw, starting with what was serving the client well. That simple lens – serving the client well – changed the entire focus of their observations to include the full range of the client’s experience. Instead of looking just for impairments and symptoms, the participants began to see strengths as well as struggles, and the person behind both.
Two questions, both offering immediate and substantial improvement in documentation. I suspect that they also will provide immediate and substantial differences in staff-client interactions.
What was your experience? What is serving this person well?
Lee Ann Slayton
President, Slayton Consulting, LLC
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