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Documentation - If it Isn’t Written Down - It Wasn’t Done

Documentation - If it Isn’t Written Down - It Wasn’t Done. Jonda Clemings, MSEd, LSW. Outline for Training. What should we document? Why should we document? How should we document?. What Should We Document?. Functional limitations & abilities Barriers that led to homelessness

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Documentation - If it Isn’t Written Down - It Wasn’t Done

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  1. Documentation - If it Isn’t Written Down - It Wasn’t Done Jonda Clemings, MSEd, LSW

  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

  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

  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 Ohio State 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

  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

  29. Bloom’s Taxonomy

  30. Whose Goal Is It? • Participant agreement & responsibility • Central issue & priorities • CM - supporting role

  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

  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

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