Guidelines for Effective Documentation

Guidelines for Effective Documentation 

Clear, complete, and accurate documentation helps protect the health and safety of the person you support, and at the same time protects you. This course will guide you towards a thorough understanding of best practices in professional documentation. You will also learn why it is important to record specific activities or events, different types of documentation, how to effectively complete documentation, and the importance of maintaining confidentiality when you document. In this course, you will learn guidelines for ensuring that your documentation adheres to legal, ethical, and programmatic standards. As you proceed through this course, you will identify factors that affect the quality of your documentation. You will learn strategies that can be used to manage documentation effectively. You will also investigate methods to individualize documentation systems to best gather data, and document progress related to the goals and services of the people you support. This course is written for direct support professionals and frontline supervisors who support people with disabilities. This training program is based on the RBT Task List and is designed to meet the 40-hour training requirement for the RBT credential. This program is offered independent of the BACB. Current Link:


Hours: 3.00


Certificates provided by accrediting body (2 Match)

National Alliance for Direct Support Professionals


This activity is approved for 3.00 contact hours.

National Alliance for Direct Support Professional Frontline Supervisor Training


Course Details

Hours: 3
Type: Online Course
Content Expiration Date: 3/31/2023
Learning Objectives:
Describe legal and ethical standards for sharing personal information about the person you support.
Examine documentation guidelines for use by staff at your agency.
Develop strategies for managing documentation duties.

Section 1. Introduction A. About This Course B. Learning Objectives Section 2: What We Document and Why A. Collin’s Emergency B. The Community Support Skill Standards Related to Documentation C. What is Documentation? D. What Should Your Documentation Include? E. The Purpose of Documentation – A Full and Safe Life F. What to do? G. Why Is Documentation Beneficial? H. For Documentation to Be Beneficial It Must Be Reviewed I. Consider Content J. Section Summary Section 3: Support Staff Roles and Associated Documentation A. Medicine, Health Care Appointments, and Health or Medical Changes B. Preventative Health Screening Documentation C. The Service Plan and Tracking Progress D. Unusual Incidents and Accidents E. Five Rules for Writing an Excellent Incident or Accident Report F. Documenting Communications G. Communication Log Book Entries H. What is Wrong with this Entry? I. Financial Management J. Under Suspicion K. Assessments L. Juggling Important Duties with Documentation Requirements M. Organize Your Charts and Files N. Coping with the Paper O. From Piles to Files – Creating a Filing System P. Section Summary Section 4: Guidelines for Effective Documentation A. Legibility, Dating, and Timeliness B. Drop the Jargon and Show Some Respect! C. Documenting Facts, Not Assumptions or Opinions D. The Case of the Wet Head and Bloody Nose E. Correcting Your Mistakes and Handling Gaps and Spaces F. Subjective vs. Objective G. Documentation: Review Section 5: Confidentiality and Ethical Practice A. What is Confidentiality? B. Respect and Dignity C. Claude’s Embarrassment D. Avoiding Breaches of Confidentiality E. Informed Consent and Releases of Information F. Exceptions to Obtaining a Written Release of Information G. When Violating Confidentiality is Okay H. Aaron’s Dilemma I. Review J. Section Summary Section 6: Conclusion A. Summary B. Course Contributors C. References D. Congratulations! E. Exam

Instructor: Deb Easley, M.S.
Deb Easley, M.S. is the Training Coordinator for Living Arrangements for the Developmentally Disabled, Inc. (LADD, Inc.) in Cincinnati, Ohio where she has worked for the past 18 years. Deb is one of the founding members of DSPATHS Credentialing Program and Ohio Alliance of Direct Support Professionals (OADSP). Her experience with DSPATHS includes being a Regional Manager, Instructor, Skill Mentor, Regional Coordinator, Regional Financial Administrator, Statewide Operations Administrator, and Curriculum Writer. Deb holds a Master of Science degree in Health Planning and Management and a Bachelor of Science degree in Education. Deb has personal and professional experience with the social and health issues encountered by people with disabilities and their families. Disclosure: Deb Easley, M.S. has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Entry level Direct Support Professionals; in the following settings: Intellectual Developmental Disabilities.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form ( or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.