Guidelines for Effective Documentation Focused Learning

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.


Hours: 1.00


Certificates provided by accrediting body (2 Match)

National Alliance for Direct Support Professionals


This activity is approved for 1.00 contact hours.

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


Course Details

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.

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 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.