Documentation

1. Documentation

2. Definition • A written record of information needed to evaluate the effectiveness of a person’s overall program or service • Types of Documentation • Narrative progress or entry notes • Specific program data collection • Communication books • Incident reports • Medication records

3. Purposes • Comprehensive history of the person served and services received • Proof that the services recommended were actually delivered • Basis for making decisions about a person’s program and services • Provides day to day information needed by staff in the provision of direct services to individuals • Required by state and federal licensing and certification regulations

4. Components • Legal document • Can be used as evidence in court • Used in making legal decisions • Access • Individual receiving services • Legal representative • Supervisory and administrative personnel • Licensing/accrediting and regulatory agencies • Government & Law Enforcement agencies • Others

5. Guidelines Make sure the record is safe from - Loss Damage Unauthorized Use Confidential - Only authorized persons can access

6. Guidelines Black or dark blue ink only (no felt tipped) Never use liquid paper, correction tape, erasable ink Errors Cross out with single line Initial over it and write error Do not make entries or sign for something you did not perform or witness

7. Guidelines Using initials – must be a key or code in the record identifying those initials Medication records Data collection forms Use only approved abbreviations List of all abbreviations must be available

8. Guidelines Date – use day, month, year Time – indicate AM or PM less room for error using 24 hr clock Make entries only after the fact or after observation has been made Keep notations in chronological order Late entries Making reference to another person Do not use another persons name when documenting Refer to the other person as “another consumer” Continuing an entry on next page

9. Requirements of Documenting in Daily Notes • Complete Chronological History of any situation • Give a clear picture so that someone not present will understand from your notes • Answer the following questions • Who • What • When • Where • How • Why

10. Requirements of Documenting in Daily Notes • Cover the order of sequence • Before • During • After

11. Don’ts of Documenting Do not leave blank lines or spaces in progress entries Do not use only initials to sign documents requiring signatures Incomplete entries Leave out important information Use subjective or evaluative language Example: “Billy was really good this afternoon.”

12. Do’s of Documenting Use objective or descriptive language what you are writing was observed or heard by you. Document only the facts Example: “Debbie threw her fork on the floor, swore at everyone at the table, spilled her milk on the floor and tipped a dining chair backwards.”

13. Documentation for Data Collection for Outcomes and Support Plans • Recording Data for Individual Support Plans • Allows the team to make decisions about whether programs are achieving the desired effect and whether they need to be • Discontinued • Revised • Continued • Maintained CHANGES ARE MADE IN PROGRAM PLANS AS A RESULT OF YOUR DOCUMENTATION!!!

14. Documentation: Staff Communication Book • Provides a quick note to your co-workers and supervisor regarding day to day issues • Includes • Questions that don’t need an immediate response • Notifications • Tasks that need to be done • Compliments and praise to co-workers and supervisor

15. Documentation: Day Program Communication Book • Document things that happened during your shift that the day program may need to know about • Includes • Injuries or illness • New medication orders • Upcoming appointments • Transportation issues • Activities/events to encourage discussion with consumer • Misc. questions

16. Data privacy

17. Definition • All information on person’s served that has been collected by this program or from other sources for program purposes, their presence and status within our program

18. Examples of Private Data • Risk Management Plans (RMP) • Individual Program Plans (IPP) • Behavior Management Plan (BMP) • Medical Information • Financial Information • Individualized Service Plan (ISP) These are just a few examples.

19. Who Can Access • The individual • Legal Representative • Employees • Local social service agencies • Human Service Boards • Ombudsman • Other • Anyone the law says can view the data

20. Informed Consent In order to share or exchange (give or receive) information about the individual, we must obtain written authorization (informed consent) from the individual (if own guardian) or the legal representative

21. Informed Consent Just because someone is a family member does not automatically mean that we can share information with them If a family member is not the legal representative, an informed consent must be signed by the legal representative indicating information can be shared and determines what information we can share

22. Informed Consent • Must include the following: • Why data is being collected • How information will be used • Whether they can refuse or if legally required to furnish information • Known consequences of providing or refusing to disclose • Who we can share the information with • What the individual can do if they believe information is incorrect or incomplete • How the individual can see/get copies of the data

23. Consent Forms • Must include the following: • Be written in plain language • Be dated • Identify who or what agencies will get the information • Specify what information is to be released • Specify the purpose of the information • Include an expiration date Consent can be withdrawn at any time.

24. Staff Access to Private Data • Policies and procedures on confidentiality and data privacy apply to all program staff, volunteers and agencies or individuals under contract with FII • Access to Private Data is on a need to know basis Confidentiality and Data Privacy should be maintained at all times!!!!