Transcript Document
Documentation - If it Isn’t Written Down It Wasn’t Done Jonda Clemings, MSEd, LSW Outline for Training • What should we document? • Why should we document? • How should we document? What Should We Document? • • • • Functional limitations & abilities Barriers that led to homelessness Program adherence General observation Why Should We Document? • Professional ethics • Guarding against liability • Social responsibility • Consumer benefits • Requirement How Should We Document? • Precisely • Objectively • Avoid documenting outside scope of practice – Diagnosing Documentation Guidelines • • • • Follow agency policy Permanent ink Avoid backdating Chronological order Documentation Guidelines • • • • No blank space Sign, credentials, date Legible, correct grammar Avoid clichés Documenting Guidelines • Be specific, factual • Progress or lack of • Document only services you provide Quic kTime™ and a TIFF (Uncompressed) decompressor are needed to see this pic ture. On-Going Assessments • Assess • Review & revise regularly • Plan • Implement • Discuss strengths, weaknesses, and obstacles Maintaining a Case File Why is it Important? • Quick access to information • Enhance service delivery • Continuity of care • Record of progress and goal attainment Maintaining a Case File Why is it Important? • History of behavioral patterns • Compliance with regulations • Records accomplishments Building a Case File What Should Be Included Identifying Information & Picture ID Ohio State ID QuickTime™ and a TIFF ( Uncompressed) decompr ess or are needed to see this picture. • Drivers license • State ID • Birth certificate Social Security Cards Homeless Status PSH • On the street • Emergency shelters • Transitional housing coming from streets and emergency shelter 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 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 Housing History • Why moved • Type of housing • Difficulties maintaining housing • Barriers • Housing needs Disability Status • Long-term, indefinite duration • Impedes ability to live independently • Disability could be improved with suitable housing Disability Status • Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use • Written documentation must come from credentialed professional Consent Forms • • • • Basic elements of consent Informed choice Overall experience Voluntary participation Educational & Vocational Assessment • Abilities • Interests • Personality Employment History • • • • • Gaps in employment Positions held Frequency of job changes Skills Strengths Criminal Background • Criminal history as it impacts housing & employment Psychosocial Assessment • • • • • • Mood & affect Cognitive functioning Memory Communication Appearance Mobility Health Assessment • • • • Medications Medication log Allergies Illnesses Service Plan • Goals/objectives while in program • Drives service planning SMART Objectives • • • • • Specific Measurable/observable Attainable within time & conditions Results-oriented Targeted to the identified need & impact Bloom’s Taxonomy Whose Goal Is It? • Participant agreement & responsibility • Central issue & priorities • CM - supporting role Progress Notes • Refer to service plan • Describe progress • Interventions provided Income Verification • Amount of income • Sources of income • Proof of income Incident Reports • • • • What happened When it happened Others involved Follow-up Discharge Summaries • • • • • • Reason for discharge Income sources Income amounts Destination Progress made Referrals made Charting Legally Sensitive Situations • Objectivity • Nonjudgmental description • Accuracy • Completeness • Legibility • Justify actions taken Dissatisfied Consumer • Utilize “quotes” • Don’t label - describe • History or crisis patterns • Attempts to satisfy • Choices provided made • Never characterize Noncompliance • How person refused to comply • Failure to provide information • Attempts to remedy • Review of procedures Confidentiality • HIPAA • Minimal access - need to know • Privileged communications Peer Review • • • • Impartial review Share expertise Diversity of opinion Provide suggestions Quality Monitoring • Look at process and outcomes • Drive improvement • Accountability • Refine service delivery • Track integrity and effectiveness Sample Forms Questions Coalition on Homelessness and Housing in Ohio Jonda Clemings, MSEd, LSW 175 S. Third St. - Suite 250 Columbus, Ohio 43215 Phone 614-280-1984 Fax 614-463-1060 www.cohhio.org [email protected]