Documentation Training

1. DOC UMENTATION Michelle Valenciano Hemm, MA, LPC , NC C , LC DC

2. How many times have we heard this? “If it’s not documented in the medical record then it didn’t happen.”

3. The answer is NOT to avoid or shy away from documenting in the medical record. Documenting is a critical component to the delivery of healthcare.

4. Documentation is a tool to:  Ensure continuity of care as it serves as a communication tool among healthcare providers  C reate a database to evaluate effectiveness of treatment  Facilitate research  Plan and evaluate a patient’s treatment  Substantiate billing  Recollect a memory and/or justify/defend care provided.  C reate a permanent record for the patient’s future care

5. Document intelligently and clearly. • Signatures must be person’s “Given Name” NO nicknames, middle names or name you wish your mom had given you. • If you have a credential, it must be included with your signature. • Spelling and grammar are important, use your spell check. Read your document before you close it out.

6. Below are a few tips to help protect against allegations of falsifying a medical record:  Date, note time, and sign every entry  Make entries immediately or soon after care is given  Write legibly  Be thorough, accurate, and objective  Only use approved abbreviations

7. Documentation is a form of communication…  All documentation should be done in a timely manner and immediately placed in the client’s chart.  All Documentation will be entered into the State Electronic Health Record: C MBHS  If documentation is written it must contain: C lient Name C lient Number Author’s Printed Name Author’s Signature (If credentialed, the credential must be included.) Date  When an addendum is made, it may be necessary to also verbally communicate this information to appropriate personnel.

8. Documentation is only as valuable as the legibility of the note. • If a note is unreadable due to penmanship or articulation then it serves no purpose and can do more damage. Poor Documentation can result in audit findings and returned funds.

9. Document Everything!!! • Document all interactions with or about the patient, face-to-face or over the phone.

10. A Well-documented C hart: Is all about continuum of care Leaves fewer opportunities for a reviewer to allege you failed to provide a service or communicate vital information. A well-documented chart can serve as an independent witness to the care provided.

11. Other Documentation In the course of the work day, we all document on a variety of forms or logs. These may include:  Incident reports  Unit logs  C ensus Reports, etc.

12. Incident Reports Adverse Event • Post an event; communication is paramount. • C ommunication should be both verbal and written. • Documentation should be objective and only state the facts.

13. Incident Reports  Incident Reports are used to communicate information to other people and to document significant events.  Staff should prepare an incident report when: Injury to individual occurs or is caused to others Aggressive behavior is directed at others Self-abusive behavior or endangering/threatening others occurs Serious illness and/or hospitalization occurs Death is imminent or death occurs C ases of property destruction Serious disruptive situation while in the community Illegal or unusual problematic behavior

14. Incident Reports cont.  These are only a few examples of what should be reported  Please Note: If you are unsure about whether or not to complete an incident report, write one!

15. Incident Reports cont.  Name of the person receiving services if any  Name of person completing report  Date, time, and location of incident  Type of incident (e.g., hospitalization, injury, abuse)  Description of incident (narrative)  Action taken  Persons notified and follow-up needed (if any)  Review by Director or designee

16. Unit Log • A tool to communicate from one shift to another. • A legal document that should be treated as other legal documents are treated. • At beginning of shift, read log and sign in. • At end of shift enter any vital information and sign out.

17. C ensus Report The census report severs many purposes. • Account for days that a client is with us. • Used for billing of services. • Used to collect data necessary for grant writing.

18. Every document that you complete should be given complete attention and filled in: • C ompletely • Accurately • Legibly • Signed and dated

19. Final Thoughts  The record serves as a log of communication providing insight into: 1. what was said 2. when it was said 3. Specifically, to whom it was said 4. and the response given

20. POST TEST

21. Thank You and Have a Great Day! Great job.