As an occupational therapist, working as an independent contractor, I have been asked quite frequently, what programming do I use for notes. Well, I use Microsoft OneNote. I love the versatility of this program and the auto-save feature. If I need run to my next appointment, I never have to worry if I have saved the notes that I have just written. Notes are always legible and you can make templates for note forms that you use regularly.
One thing that I really like about OneNote is that I can create my assessment rubrics [you know that I am a big fan of rubrics] and save each one as a template.
Do you see those little green boxes? Just one click [if on a computer] or tap [if on a tablet] and OneNote will check the box for you. Once you set up your rubrics and save them as templates [you must save templates only once], they will be available to you forever. You then have accurate and transparent data collection for each session. I recommend using one page per session. You can also make templates in Excel to graph your data.
I recommend making a notebook for each individual patient. Templates are available across all notebooks that you create [another cool feature]. When you discharge the patient, import the Excel file into OneNote and you will have complete and accurate data of the patient’s progress [with a graphic] over the course of your treatment. You will have to enter the data separately into the Excel file but it is faster and more accurate.
My book, Using Rubrics to Monitor Outcomes in Occupational Therapy, explains how to develop and modify a rubric and the importance of accountability and transparency in our documentation. Adapting to the new regulations can only support and teach others about what we do so that we do not get swallowed up by professions waiting to do so. While this may be initially time consuming, once you have your assessment rubrics in place, documentation will be easy. Remember, you can e-mail a page using a HIPPA Compliant e-mail system [like hushmail.com] or print it for your records.
Another of my favorite therapy areas is teaching students how to take notes. Taking notes is not easy. Students must be able to respond to auditory cues with a pen/pencil or a keyboard. Some students feel the need to take down every word, while others can take down the highlights. Since I am an occupational therapist, my job is to teach students how to respond to environmental cues with movement. So I would like to talk about taking notes in my favorite note-taking program, OneNote.
There are a number of reasons to set up note – taking templates or forms in OneNote. For example, this T-Chart can be used for a number of different classes and discussions within a class. Prompts that may indicate that a T-Chart should be used are: Compare/Contrast; Conversely; Vocabulary Words/Definitions; Pros/Cons, etc. This note-taking template can also be used for pre-algebra/algebra or anywhere where there is a rule and a sample. The Cornell style of note-taking also uses a asymmetrical T-Chart for cues and notes.
Much of the job is already done for the student. The page is already formatted for the student. I find that formatting is often part of the delay and disorganization in taking notes. If you click on the date, a little calendar appears and the date can be easily changed (calendar will indicate the correct date). The same can be done for the time. Rows can easily be added to the table by clicking on the appropriate icon in the ribbon at the top of the screen or by right-click and then click on Table. The color of the page and print can also be changed to address any visual concerns.
The real trick is learning the verbal prompts so that the appropriate form can be identified and opened. The great part of this system is that this is an auto-save program! If the student closes the program before saving, the work will still be there. Another factor to consider is keyboarding speed and accuracy. Figure out if the student can take dictation on the keyboard accurately before recommending this method to any student.
Many therapists are looking for a way to document on the run. This means that they are looking for a way to become paperless, much like many other professions. This saves the mounds of paper that over the course of the years has become insurmountable. I frequently talk about using MS OneNote for all of these documents. Not only can you create a template like this one. You can also print out your documents for immediate submission if you have access to a printer. In the event that you do not have access to a printer, you can certainly e-mail it through a HIPPA compliant service, like hushmail.com.
If I really need to print out a report for one of those meetings that are occurring today, you can absolutely do so.
You can do the same thing with your Medicaid notes and many other note forms that you will need. I have never had to use a specific form for a consult but I developed one anyway for me to keep track. Each of the cells in these tables will expand to the size needed, once you start entering information.
This is the note form that I created for my Medicaid notes. It works well and is accepted by any agency that I work with.
I do not find it as easy to create templates in the free version of Evernote. I am a OneNote girl!