D is for Documentation

Documentation is a standard of practice for music therapists. Clinical documentation seems to be a difficult one for students to learn. Here’s how I teach it:

  1. Use a Template. I have created documentation for most of the jobs I’ve had, so I draw from that experience. For each population, or setting, I look at what the setting requires, or what information I need. I also look at the AMTA Standards of Practice for Documentation to make sure I include all of those requirements.
  2. Provide examples. Most students know how to write a scholarly paper, but don’t know how to write a clinical session note. So I write a few examples so they can identify some phrases and vocabulary, along with the style of an objective, professional session note based on observable client responses.
  3. Explain the purpose. I’ve found that if I explain that documentation is used to protect the client and the music therapist, should there be a law suite, as well asĀ  to explain what happened and why to people who will pay for music therapy, it seems to help students understand it better. Students often write a list of the strategies they used. I explain that a doctor or payor won’t care if the client could sing, but they have to explain why the fact that the client sang was meaningful or functional. What’s the importance behind the MT strategy?
  4. Give lots of practice and feedback. I have the students write a clinical documentation note for every session for all semesters of practicum and then give feedback on how to write it differently, when needed, each and every time. By the time they get to internship, they should have a fairly good idea of how to write an objective, clinical note. I also make them use a black pen, because it forces them to write quickly, and think carefully before they write, learn how to cross out a mistake correctly, and to make fewer mistakes because they can’t correct it.

I didn’t really learn this skill until my internship and I struggled with it. So I hope that it helps the students to learn it before internship. My documentation skills have served me well–I learned early in my career that I don’t often get paid for documentation, and I quickly got tired of doing a bunch of documentation on Friday night for the week. So I created a system that allowed me to document before I left each client or setting, and that helped me to not have to work during my personal free time.

If you need help with documentation, I’d be happy to share my secrets with you in a professional supervision session for just $60. Contact me for details and to schedule a session.