Documentation Made Easy!
I am sure you did not become an animal behavior consultant to spend hours writing behavior plans and other reports. However, for most of us, it is part of what we do and, I think, a necessary part of our work. It helps us stay focused and track progress.
What if I told you there is an easier way to get your documentation done while with your clients so there is no need to spend hours after you work with them.
My background is in health care, where I once taught clinicians how to do what is called collaborative or concurrent documentation (CD). This is a process by which we document with the client present. The behavior consultant and clients collaborate in the documentation process, so it is not done in isolation after the session.
Think about the last time you went to any of your medical providers or your veterinarian. I would bet that they were typing as you sat with them in their office. I would also bet, for the most part, after you left they were done documenting and may have even provided you with a copy of the information on your way out the door. CD can also be done by animal behavior consultants, and it is even easier than a human health care provider because what we do is not regulated like the human health care industry.
As a previous health care provider, and more specifically, a behavioral health clinician who worked with clients in quality and compliance, I think of animal behavior consulting as family therapy but with the pet, in my case, canines. CD can enhance the value of the sessions, as it gives clients real-time feedback, which will increase family buy-in to treatment. In my experience, CD can save you lots of time, which eliminates the feeling that you are always having to catch up on documentation. If we do this documentation in real-time, there is less room for error so our documentation is more accurate. This is especially true for those of you seeing clients back to back. This will decrease your stress and improve your quality of life and sense of well-being.
So how can this be done? CD can either be done in a way that families will like or in a way that makes them uncomfortable. If done right, it can improve client engagement and client involvement. Like anything else, it takes some practice!
There are many ways to do this. For me and my business, I have developed templates of the information, behavior modification techniques, and the recommendations I use with many of my clients.
My templates are in Apple Pages, but you can use Microsoft Word or any program that you are comfortable with. The templates allow you to start from a fresh copy of your documentation every time rather than having to clear up a previously used version. I have versions of my templates for female and male animals on my laptop, which I bring to all of my appointments. For example, for most of my clients I know I will be recommending both enrichment and a visit to the veterinarian to ensure there are no medical concerns that are affecting behavior. Why should I write these phrases over and over again, when I can just have it as part of a template? The other piece of information I always have in my reports is a bit of background on the dog as stated below.
For example, here is very small snapshot of my template:
NAME was adopted at AGE weeks/months/years old from a breeder/ rescue. NAME’s date of birth is DATE. NAME was xxx old on the date of the initial assessment.
If I take the time to make a template with most of my standard recommendations, then more than half the work is done! I don’t have to write the same things over and over again. I just find and replace the canine’s name and tweak my recommendations and behavior modification plan as appropriate for that client.
I usually update my templates every six months to a year as things change for me and how I work. Once you have a template it is easier to sit with your clients and complete their individualized plan.
When I meet with clients in person or remotely for the first time, I introduce myself and then let them know about my process of report writing. I explain that I will be typing as we chat so I can capture important information about their canine companion. I explain to them that I will email a copy of the report to them and any other pet professional who is working on this team, for the betterment of the canine.
At sessions, I will ask, “What are your goals and what do you want to get out of our session today?” This all gets typed into the report as it is discussed. This can also help with the clients ownership of those goals as they get them in writing.
The first appointment is my fact-gathering time. I will type while getting this information. Subsequent appointments are a bit easier because, for the most part, my templates cover most of the behavior modification protocols. I do often need to change them to meet the specific needs of the client in front of me, but it is far less work than writing from scratch.
As I sit with the client, gathering the information, I type directly into my template so I do not have to go back and rewrite anything. I will delete anything in my template that does not apply and tweak my template to fit the canine’s specific behavior modification program.
After the assessment, when I have decided on behavior modification techniques, as I am typing I will explain the technique I recommend. I will then close my laptop and demonstrate the behavior modifications techniques with my own dog if it is a remote session and with their dog if it is in person. I will have the client practice the behavior and I will coach the client as needed. At the end of our session, I go back to my laptop and the client’s report and review the main points of the session, highlighting anything important. I will also ask if there are any questions.
I am finding that when working remotely, or for tele-training, CD is easy to do. I do find it is helpful to have two screens though. One for viewing the client and one for documenting. I will often share my screen to show clients short pre-recorded videos or even my report and recommendations. When I work in person I have the same procedure.
Prior to emailing the report to the client and others as approved by the client, I will reread the report on my own, to ensure that there aren’t any typos. I typically email the report within 24 hours (usually much sooner) from the time of the appointment. This way the client can get started on what I just taught them and have something to refer back to.
If you project CD as a valuable interactive process, your clients will perceive it this way. I think about documentation as an essential element of the process instead of just paperwork. I think it gets the humans engaged and committed to the protocols we outline for them. I also think it makes them more accountable to the process.
For example, we have had clients from a household where there are lots of humans working with the dog. The family decided to hang our report on the refrigerator so it is readily available for everyone to view and keeps everyone on point. It is also wonderful to be able to cross out goals that are met. At the beginning of each session, we will review what we did the session prior and see where we are. I will update anything of significance that the client has reported. If something is not working as intended we can tweak the protocol. We can also see what goals have been accomplished and what needs further work.
I really try to give the humans enough to do while not overwhelming them. We all know that, with busy lives, if we give clients more than they can handle, not much will get done. If it is on paper for the client, it is there for them to refer to and review.
There are times when CD is not appropriate or takes a back seat. I will take limited notes if I am working with a person who is not fluid with the hands-on part of working with their animal and the animal is clearly very uncomfortable. Also, I usually won’t do CD with over-aroused dogs who are really mouthy and biting, because it is more important to work with the animal in front of me to prevent accidental injury and to be able to redirect them in a timely manner.
I have not had any client be put off by my documenting with them, as I think they are used to it with other providers. They like getting a copy of the report emailed to them within 24 hours of our meeting; most look forward to it. I also recommend sending your report to any other pet professionals working with the client, such as a veterinarian, dog walker, or groomer. I get written approval from the client to do this on my training contract with either a wet signature, or more commonly now, an e-signature. This helps everyone be on the same page and can provide additional information to other disciplines.
For example, if the dog is barking and lunging while on leash and there is a dog walker involved, the report could have walking recommendations that would be helpful for the dog walker to know and follow. I will also invite the dog walker to join us for a session that involves walking. For a recent client, we observed and noted in our report that the dog urinated small amounts frequently, five times in one hour. This resulted in a strong recommendation to see a veterianarian. I have a section in my report for recent or current medical issues so the veterinarian can easily find that information and not have to read the whole report.
In another recent case, we noted that the dog was sensitive to the client touching the dog’s hips. I don’t think the veterinarian was aware of this, and the client did not think to tell the veterinarian about it because the dog has always been this way. With groomers, we have worked on nail trims and forwarded that information, so the groomer is aware of the protocols we are working on with the dog. Other professionals have been very appreciative of getting this additional information that they may not otherwise have. It also may make their job easier. An added benefit is that other pet professionals get to know you and your work and may be more likely to refer to you.
As you can see, there is tremendous value in concurrent documentation. It has really helped me in my work and has helped our clients be more successful in their training. I suggest you give it a try and see what works best for you! Happy documenting!
Beth Friedman is a Certified Dog Behavior Consultant, Fear Free Animal Trainer who has graduate degrees in both social work and public administration. She and her husband own Canine Companion Consulting where they train dogs one human at a time, using positive, research-based methods since 2007. The husband and wife team specialize in special needs canines and conduct tele-training, in person consultations, as well as group classes. Beth also scores CDBC applications for the IAABC. Feel free to contact them at CanineCompanionConsulting.com