Guidelines for Effective Documentation Focused Learning

 

Clear, complete, and accurate documentation protects the people you support and protects you too. This course explains why documentation is important and the key factors that affect the quality of your documentation. It covers best practices for keeping good records that adhere to legal, ethical, and programmatic standards. This course is written for staff who support people with disabilities.

$19.95

Hours: 1.00
REL-IDD-OADSP-GEDFL

Certificates

Certificates provided by accrediting body (2 Match)

National Alliance for Direct Support Professionals

1.0 HOURS


This activity is approved for 1.00 contact hours.

Non-Licensed Direct Care (DSP, HHA, CNA, DCW, PCA, IHA, NA)

1.0 HOURS


Course Details

Course Code: REL-IDD-OADSP-GEDFL
Hours: 1
Type: Online Course
Content Expiration Date: 11/30/2020
Learning Objectives:
Explain why accurate and consistent documentation is essential for providing services.
Develop a practice of documentation that prioritizes a) the preferences of the individual and b) clear communication between coworkers.
Distinguish between an objective and useful log entry and an inappropriate, unethical, or subjective log entry.

Outline:
Section 1. Introduction
A. About This Course
B. Learning Objectives
Section 2: What We Document and Why
A. Collin’s Emergency
B. What Went Wrong?
C. What is Documentation?
D. Support Staff & Documentation
E. Why Is Documentation Beneficial?
F. Documentation as Defense
G. Section Summary
Section 3: Types of Documentation
A. Tracking a Service Plan
B. Health Monitoring
C. Documenting Communications
D. Communication Log Book Entries
E. Incidents and Accidents
F. Writing Excellent Reports
G. Juggling Important Duties with Documentation Requirements
H. Section Summary
Section 4: Guidelines for Effective Documentation
A. Effective Documentation
B. Legibility, Dating, and Timeliness
C. Correcting Mistakes
D. Consider the Content
E. Claude’s Embarrassment
F. Dignity and Respect
G. Cindy’s Log
H. Document Facts, Not Assumptions or Opinions
I. Drop the Jargon
J. Taking Sides
K. Subjective vs. Objective
L. Section Summary
Section 5 Conclusion
A. Summary
B. Put Into Practice
C. Congratulations!

Expert Reviewer: 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 and intermediate level Direct Support Professionals; in the following settings: Intellectual Developmental Disabilities.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at [email protected]
All courses offered by Relias Learning, 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.
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.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.
Accommodations
If you require special accommodations to complete this module, please contact Relias Customer Support by calling (800) 381-2321 or emailing [email protected]