Guidelines for Effective Documentation

Outline:
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

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.