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. You will also learn guidelines for ensuring that your documentation adheres to legal, ethical, and programmatic standards. In 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, and will investigate methods to individualize documentation systems to best gather data and 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.
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. How Is Documentation Beneficial? H. For Documentation To Be Beneficial It Must Be Reviewed I. Consider Content J. Section Summary Section 3: Direct Support Professional Roles and Associated Documentation A. Medicine, Health Care Appointments and Health or Medical Changes B. Preventative Health Screening Documentation C. The Person’s Plan and Tracking Progress D. Unusual Incidents and Accidents E. 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. Reduce Paper and File Documents Electronically Q. 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. Section Summary 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. Section Summary Section 6: Conclusion A. Summary B. Put Into Practice C. Congratulations
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.
Access to over 1,450 courses! Access to 1,450+ courses for one low price.