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2. Outline for Training What should we document?
Why should we document?
How should we document?
3. What Should We Document? Functional limitations & abilities
Barriers that led to homelessness
Program adherence
General observation
4. Why Should We Document? Professional ethics
Guarding against liability
Social responsibility
Consumer benefits
Requirement Social responsibility
Homelessness is an indicator of functional impairment and often a marker of disability.
People with disabilities constitute the “chronically homeless” population in America.
Disability benefits can help people end and prevent homelessness.Social responsibility
Homelessness is an indicator of functional impairment and often a marker of disability.
People with disabilities constitute the “chronically homeless” population in America.
Disability benefits can help people end and prevent homelessness.
5. How Should We Document? Precisely
Objectively
Avoid documenting outside scope of practice
Diagnosing
6. Documentation Guidelines Follow agency policy
Permanent ink
Avoid backdating
Chronological order
7. Documentation Guidelines No blank space
Sign, credentials, date
Legible, correct grammar
Avoid clichés
8. Documenting Guidelines Be specific, factual
Progress or lack of
Document only services you provide
9. On-Going Assessments Assess
Review & revise regularly
Plan
Implement
Discuss strengths, weaknesses, and obstacles The participant’s progress toward achieving the goals in the service plan must be documented
Service plans should have a column to record outcomes:
Provides a quick and easy way to review a participant’s progress.
Provides program monitors with performance measurement information without having to read through progress notes
Progress notes should provide a more detailed description of events that have occurred and any changes in goals or objectives
Goals and objectives should be reviewed and revised on a frequent and regular basis.
Allows the participant to see what has been achieved.
Provides an opportunity to discuss strengths, weaknesses and obstacles.
Provides for the development of new goals.
The participant’s progress toward achieving the goals in the service plan must be documented
Service plans should have a column to record outcomes:
Provides a quick and easy way to review a participant’s progress.
Provides program monitors with performance measurement information without having to read through progress notes
Progress notes should provide a more detailed description of events that have occurred and any changes in goals or objectives
Goals and objectives should be reviewed and revised on a frequent and regular basis.
Allows the participant to see what has been achieved.
Provides an opportunity to discuss strengths, weaknesses and obstacles.
Provides for the development of new goals.
10. Maintaining a Case FileWhy is it Important? Quick access to information
Enhance service delivery
Continuity of care
Record of progress and goal attainment
11. Maintaining a Case FileWhy is it Important? History of behavioral patterns
Compliance with regulations
Records accomplishments
12. Building a Case FileWhat Should Be Included
13. Identifying Information & Picture ID Drivers license
State ID
Birth certificate
14. Social Security Cards
15. Homeless Status PSH On the street
Emergency shelters
Transitional housing - coming from streets and emergency shelter
16. Homeless Status TH Same as PSH - and
Evicted within a week - no subsequent resources
Discharged within a month - no subsequent resources
Fleeing domestic violence - no subsequent resources
17. Chronic Homeless Status Unaccompanied individual
Disabling condition
Living on streets or emergency shelter
1 continuous year homeless or 4 episodes of homelessness in 3 years
18. Housing History Why moved
Type of housing
Difficulties maintaining housing
Barriers
Housing needs
19. Disability Status Long-term, indefinite duration
Impedes ability to live independently
Disability could be improved with suitable housing
20. Disability Status Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use
Written documentation must come from credentialed professional
21. Consent Forms Basic elements of consent
Informed choice
Overall experience
Voluntary participation
22. Educational & Vocational Assessment Abilities
Interests
Personality Holland’s codes for vocational interests
Realistic - outdoors; hands-on occupations
Investigative - scientific
Artistic - creative
Social - counseling and teaching
Enterprising - management and sales
Conventional - clericalHolland’s codes for vocational interests
Realistic - outdoors; hands-on occupations
Investigative - scientific
Artistic - creative
Social - counseling and teaching
Enterprising - management and sales
Conventional - clerical
23. Employment History Gaps in employment
Positions held
Frequency of job changes
Skills
Strengths
24. Criminal Background Criminal history as it impacts housing & employment
25. Psychosocial Assessment Mood & affect
Cognitive functioning
Memory
Communication
Appearance
Mobility
26. Health Assessment Medications
Medication log
Allergies
Illnesses
27. Service Plan Goals/objectives while in program
Drives service planning
28. SMART Objectives Specific
Measurable/observable
Attainable within time & conditions
Results-oriented
Targeted to the identified need & impact Why have objectives? Creating clear objectives during the service planning process serves the following purposes:
Helps consumer and staff integrate all aspects of the plan
Serves to connect implementation and evaluation to define impact
Provides a clear focus for development and implementation
Forms the basis for evaluating outcomes and successes
Why have objectives? Creating clear objectives during the service planning process serves the following purposes:
Helps consumer and staff integrate all aspects of the plan
Serves to connect implementation and evaluation to define impact
Provides a clear focus for development and implementation
Forms the basis for evaluating outcomes and successes
29. Bloom’s Taxonomy
30. Whose Goal Is It? Participant agreement & responsibility
Central issue & priorities
CM - supporting role In order to create an effective service plan, there has to be an agreement about the work to be done.
The participant and case manager may be different ideas about what the central issue is and what are the priorities.
The participant must feel that they are working towards getting what they want.
Case managers should be aware of their own agenda and be willing to give up the idea that we can control someone else’s life.
On the flip side of that, participants must be willing to take responsibility for their own lives.
In order to create an effective service plan, there has to be an agreement about the work to be done.
The participant and case manager may be different ideas about what the central issue is and what are the priorities.
The participant must feel that they are working towards getting what they want.
Case managers should be aware of their own agenda and be willing to give up the idea that we can control someone else’s life.
On the flip side of that, participants must be willing to take responsibility for their own lives.
31. Progress Notes Refer to service plan
Describe progress
Interventions provided
32. Income Verification Amount of income
Sources of income
Proof of income
33. Incident Reports What happened
When it happened
Others involved
Follow-up
34. Discharge Summaries Reason for discharge
Income sources
Income amounts
Destination
Progress made
Referrals made
35. Charting Legally Sensitive Situations Objectivity
Nonjudgmental description
Accuracy
Completeness
Legibility
Justify actions taken
36. Dissatisfied Consumer Utilize “quotes”
Don’t label - describe
History or crisis patterns
Attempts to satisfy
Choices provided made
Never characterize Be specific. Effective charting is factual. Use words that reference participant reaction, attitude, and symptoms. Mention specific progress or lack of progress.
Don’t label a participant’s behavior without describing it. For example: harry Homeless was anxious as evidenced by pacing, hand writing, and fast paced speech.
Never characterize the participant’s behavior with unflattering and unprofessional adjectives such as spaced out, flipped out, drunk as a skunk, etc.
Don’t use the words appears or seems to without adding a statement such as as evidenced by or as indicated by
Do use participant quotes, or paraphrase what he/she says – remember to utilize quotation marks if using quotes
Be specific. Effective charting is factual. Use words that reference participant reaction, attitude, and symptoms. Mention specific progress or lack of progress.
Don’t label a participant’s behavior without describing it. For example: harry Homeless was anxious as evidenced by pacing, hand writing, and fast paced speech.
Never characterize the participant’s behavior with unflattering and unprofessional adjectives such as spaced out, flipped out, drunk as a skunk, etc.
Don’t use the words appears or seems to without adding a statement such as as evidenced by or as indicated by
Do use participant quotes, or paraphrase what he/she says – remember to utilize quotation marks if using quotes
37. Noncompliance How person refused to comply
Failure to provide information
Attempts to remedy
Review of procedures
38. Confidentiality HIPAA
Minimal access - need to know
Privileged communications
39. Peer Review Impartial review
Share expertise
Diversity of opinion
Provide suggestions
40. Quality Monitoring Look at process and outcomes
Drive improvement
Accountability
Refine service delivery
Track integrity and effectiveness
41. Sample Forms
42. Questions
43. Coalition on Homelessness and Housing in OhioJonda Clemings, MSEd, LSW175 S. Third St. - Suite 250Columbus, Ohio 43215Phone 614-280-1984Fax 614-463-1060www.cohhio.orgjondaclemings@cohhio.org