Ep #115: The Missing Link Between Documentation and Team Trust

Episode 115, The Missing Link Between Documentation and Team Trust.

Welcome to Clinicians Creating Impact, a show for physical therapists, occupational therapists, and speech-language pathologists looking to take the next step in their careers and make a real difference in the lives of their clients. If you’re looking to improve the lives of neurodiverse children and families with neurological-based challenges, grow your own business, or simply show up to help clients, this is the show for you. 

I’m Heather Branscombe, Therapist, Certified Coach, Clinical Director and Owner of Abilities Neurological Rehabilitation. I have over 25 years of experience in both the public and private sectors, and I’m here to help you become the therapist you want to be, supporting people to work towards their dreams and live their best lives. You ready to dive in? Let’s go.

Hi there, and welcome back to the podcast. Today, I wanted to start this episode with a confession. Now, if you’ve worked with me, this may or may not be new information or even a surprise, but maybe it is. Either way, I feel like I should disclose it here today as you’re listening. And here’s my confession: I have never actually loved documentation.

Truth be told, it has always felt like something I have to do, not something I want to do. It’s the thing at the end of the day or at the end of the session that can feel like more than a bit of a drain. It’s a big drain. And I know that I’m not alone in that. Most clinicians I talk to actually feel the same way. So maybe you do as well. It can feel like a checkbox and it can feel like it’s just there to meet college requirements. And while that is part of it, over time, I’ve noticed that I made a few small shifts in how I think about documentation that has made it feel more useful. And honestly, a little bit more engaging. Not because it suddenly became fun. It’s not. I can tell you it’s not. But because it has started to have a purpose beyond just compliance.

And the biggest shift for me is this: documentation isn’t just a requirement. It actually can be a tool for building trust. Stay with me here. It doesn’t mean that it’s going to take away the effort. That in and of itself is not magically going to make it easier. But it does give it a different kind of meaning. And I find for myself, when something has meaning, it becomes a lot easier to engage with.

So today I want to talk you through a simple way of thinking about documentation that I have found really helpful. And it’s the idea of documentation as a trust-building tool. So I think about this in three layers. The first layer is around self-trust. When you look at documentation, do you feel clear about what you’re doing with this client? If you came back to this file next week or even in two weeks, would you be able to just pick it up and feel confident and competent in your plan? That’s that first layer. I don’t know about you, but that’s often what I would do as I would made the shift in this documentation was thinking about that self-trust.

That second is team trust. And what I mean by that is if someone else needed to understand what was happening with this client, could they do that without needing to come find you? So that could be someone on the admin team, it could be a team lead, it could be another therapist stepping in. It could be the rehabilitation assistant that you’re working with. Is your thinking visible enough that someone else can follow it? That’s why that second layer is so important.

And then the third layer is what I’ll call execution trust. Based on your documentation, could someone else actually act on this plan confidently? And again, that might be a rehabilitation assistant, it might be another team member, or really anyone supporting that client.

And again, I want to say even if you’re not currently working with rehabilitation assistants, and I’m thinking about this specifically about rehabilitation assistants, it still applies because the clearer your documentation is, the easier it is for anyone around you to support your client well. So when we start to look at documentation through this lens, it shifts from being something we just do for compliance for our college guidelines to something that actively reduces friction in our work.

Now, one of the biggest things that I’ve noticed over time is that we tend to use documentation time to think. And that’s not necessarily wrong. I used to do that all the time as well. It’s often where our clinical reasoning happens. That’s where we’re figuring things out, making decisions, adjusting plans. It can be a really important part of our process. But documentation isn’t just for thinking. It’s actually for communicating that thinking. And those are actually two different things. The thinking is for you, and the documentation is for other people.

And when those two blur together, we often end up with notes that make complete sense to us in the moment but actually are quite hard for someone else to follow. And again, that’s usually not intentional. It’s just that we haven’t separated those roles. So I just wanted to speak that out so that you can start to separate those roles. What can happen when we don’t separate those roles is that your documentation holds your thinking, but it doesn’t clearly translate your thinking. And that’s where we start to see breakdowns in trust, especially at the team level.

This brings me to something else I see quite often. As clinicians, we are trained to document. We understand that there are standards, there’s expectations, there’s a level of accountability there. But not everyone on our team is trained in the same way or held to the same standards. So if we don’t explicitly define what clear, effective documentation and communication looks like for people we’re working with, they often are left to interpret it for themselves. And that’s where that misalignment can start to happen. So I want to say this really clearly. This isn’t about people doing something wrong. If this is happening to you, you are not doing something wrong. It’s just about communication not being as clear as it could be.

And I will say that we actually see that play out in a really practical way in our organization. We have a client experience specialist in our organization and part of her role is to support families and teams when there are challenges or concerns with clients. And one of the first things she does in those situations is she goes to the documentation. Of course, she’s going to talk to the client. Of course, she’s going to talk to the team members, but that documentation is there and it’s a good first place for her to start her investigation. And specifically, if there’s a rehabilitation assistant involved, she looks to see if there is a clear support plan in place.

Now, this isn’t from a place of judgment. It’s not from a place of trying to catch anyone doing something wrong, but it is because that gives us a really quick window into the quality of the communication in this particular case. And what we notice is if there is a clear support plan, it’s much easier to see what the intention was, how things were meant to be carried out and where things may have drifted. And if there isn’t one, what we often see is not necessarily poor care but unclear communication. And that’s where the impact on our clients often comes to bear.

The clinician, in this case, the therapist, had a plan in their head. The rehab assistant is doing their best to interpret that plan. But somewhere in the middle, life gets a little bit off track. And then it can feel like something went wrong when really what was missing was a shared understanding. And we may have had that at the beginning, but that communication can be that north star that everybody can come back to.

And that’s where this idea of separating thinking from communicating can become really powerful. And here at Abilities, one of the ways we support this is separating what we call the therapy plan from the support plan. Because the therapy plan holds your clinical thinking. Again, that’s your goals, your clinical reasoning, your overall direction, the frequency of the sessions. It’s really the what and the why. But the support plan is the how. What is actually going to be done? How is it actually going to be done? And what does success actually look like?

And we can include communication and a communication plan in that. How does the supervising therapist want to be updated? When do you want to be updated? What counts as something that needs to be flagged? And if something goes off track, how do you want that to be communicated back to you? So in that way, it creates clarity in both directions.

And one important thing why we actually keep that separate from the main documentation is because it makes it much easier for the team to access and use that in real time. Now, again, you don’t need to use our exact system if you’re not working for us at Abilities, but what I would really encourage you to think about is this: Do you have a way of translating your clinical thinking into something that someone else can confidently act on? Because that’s the bridge. And if the bridge isn’t there, you end up carrying a lot more of that load yourself.

So if you’re looking to make a shift in your documentation, I would make it really simple. Run your documentation through these three layers of trust. So first, do I feel clear? Secondly, could someone else understand this without asking me? And third, could someone else act on this confidently? And if one of those questions feels a bit shaky, that’s your opportunity to refine, not to write more but to write more clearly. And then I just want to leave you with this. When your documentation is clear, you’re no longer the only one holding the impact of your work. You’re creating clarity that allows your team to support you, your client, and the outcomes that you’re all working towards. And that doesn’t just improve care. It reduces the pressure on yourself as a clinician. Clear documentation doesn’t just organize your work. It distributes the impact your work across the team.

Thank you so much for listening to this episode, and I look forward to meeting you in our next one. Talk to you soon.

Thanks for joining me this week on the Clinicians Creating Impact podcast. Want to learn more about the work I’m doing with Abilities Rehabilitation? Head on over to Abilitiesrehabilitation.com. See you next week.