Documentation - If it Isn’t Written Down - It Wasn’t Done
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Transcript of Documentation - If it Isn’t Written Down - It Wasn’t Done
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Documentation -
If it Isn’t Written Down -
It Wasn’t Done
Jonda Clemings, MSEd, LSW
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Outline for Training
• What should we document?
• Why should we document?
• How should we document?
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What Should We Document?• Functional limitations & abilities• Barriers that led to homelessness• Program adherence• General observation
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Why Should We Document?
• Professional ethics• Guarding against
liability• Social responsibility• Consumer benefits• Requirement
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How Should We Document?
• Precisely• Objectively• Avoid documenting outside
scope of practice– Diagnosing
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Documentation Guidelines
• Follow agency policy• Permanent ink• Avoid backdating• Chronological order
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Documentation Guidelines
• No blank space• Sign, credentials, date• Legible, correct grammar• Avoid clichés
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Documenting Guidelines
• Be specific, factual• Progress or lack of • Document only
services you provide
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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On-Going Assessments
• Assess• Review & revise
regularly• Plan• Implement• Discuss strengths,
weaknesses, and obstacles
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Maintaining a Case FileWhy is it Important?
• Quick access to information
• Enhance service delivery
• Continuity of care• Record of progress
and goal attainment
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Maintaining a Case FileWhy is it Important?
• History of behavioral patterns
• Compliance with regulations
• Records accomplishments
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Building a Case FileWhat Should Be Included
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Identifying Information & Picture ID
• Drivers license• State ID• Birth certificate
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
Ohio State ID
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Social Security Cards
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Homeless Status PSH
• On the street• Emergency shelters• Transitional housing -
coming from streets and emergency shelter
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Homeless Status TH
• Same as PSH - and• Evicted within a week - no
subsequent resources• Discharged within a month -
no subsequent resources• Fleeing domestic violence - no
subsequent resources
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Chronic Homeless Status
• Unaccompanied individual• Disabling condition• Living on streets or
emergency shelter• 1 continuous year
homeless or 4 episodes of homelessness in 3 years
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Housing History
• Why moved• Type of housing• Difficulties maintaining
housing• Barriers• Housing needs
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Disability Status
• Long-term, indefinite duration
• Impedes ability to live independently
• Disability could be improved with suitable housing
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Disability Status
• Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use
• Written documentation must come from credentialed professional
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Consent Forms• Basic elements of consent• Informed choice• Overall experience• Voluntary participation
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Educational & Vocational Assessment
• Abilities• Interests• Personality
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Employment History
• Gaps in employment• Positions held• Frequency of job changes• Skills• Strengths
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Criminal Background
• Criminal history as it impacts housing & employment
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Psychosocial Assessment
• Mood & affect• Cognitive functioning• Memory• Communication • Appearance• Mobility
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Health Assessment
• Medications• Medication log• Allergies• Illnesses
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Service Plan
• Goals/objectives while in program
• Drives service planning
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SMART Objectives
• Specific
• Measurable/observable
• Attainable within time & conditions
• Results-oriented
• Targeted to the identified need & impact
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Bloom’s Taxonomy
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Whose Goal Is It?
• Participant agreement & responsibility• Central issue & priorities• CM - supporting role
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Progress Notes
• Refer to service plan• Describe progress• Interventions provided
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Income Verification
• Amount of income• Sources of income• Proof of income
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Incident Reports
• What happened• When it happened• Others involved• Follow-up
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Discharge Summaries
• Reason for discharge• Income sources• Income amounts• Destination• Progress made• Referrals made
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Charting Legally Sensitive Situations
• Objectivity• Nonjudgmental
description• Accuracy• Completeness• Legibility• Justify actions taken
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Dissatisfied Consumer• Utilize “quotes”• Don’t label - describe• History or crisis
patterns• Attempts to satisfy• Choices provided
made• Never characterize
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Noncompliance
• How person refused to comply
• Failure to provide information
• Attempts to remedy• Review of procedures
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Confidentiality
• HIPAA• Minimal access - need to know• Privileged communications
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Peer Review
• Impartial review• Share expertise• Diversity of opinion• Provide suggestions
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Quality Monitoring
• Look at process and outcomes
• Drive improvement• Accountability• Refine service delivery• Track integrity and
effectiveness
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Sample Forms
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Questions
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Coalition on Homelessness and Housing in OhioJonda Clemings, MSEd, LSW175 S. Third St. - Suite 250
Columbus, Ohio 43215Phone 614-280-1984
Fax 614-463-1060www.cohhio.org