Documentation -
This presentation is the property of its rightful owner.
Sponsored Links
1 / 43

Documentation - If it Isn’t Written Down - It Wasn’t Done PowerPoint PPT Presentation


  • 63 Views
  • Uploaded on
  • Presentation posted in: General

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

Download Presentation

Documentation - If it Isn’t Written Down - It Wasn’t Done

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Documentation if it isn t written down it wasn t done

Documentation -

If it Isn’t Written Down -

It Wasn’t Done

Jonda Clemings, MSEd, LSW


Outline for training

Outline for Training

  • What should we document?

  • Why should we document?

  • How should we document?


What should we document

What Should We Document?

  • Functional limitations & abilities

  • Barriers that led to homelessness

  • Program adherence

  • General observation


Why should we document

Why Should We Document?

  • Professional ethics

  • Guarding against liability

  • Social responsibility

  • Consumer benefits

  • Requirement


How should we document

How Should We Document?

  • Precisely

  • Objectively

  • Avoid documenting outside scope of practice

    • Diagnosing


Documentation guidelines

Documentation Guidelines

  • Follow agency policy

  • Permanent ink

  • Avoid backdating

  • Chronological order


Documentation guidelines1

Documentation Guidelines

  • No blank space

  • Sign, credentials, date

  • Legible, correct grammar

  • Avoid clichés


Documenting guidelines

Documenting Guidelines

  • Be specific, factual

  • Progress or lack of

  • Document only services you provide


On going assessments

On-Going Assessments

  • Assess

  • Review & revise regularly

  • Plan

  • Implement

  • Discuss strengths, weaknesses, and obstacles


Maintaining a case file why is it important

Maintaining a Case FileWhy 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 important1

Maintaining a Case FileWhy is it Important?

  • History of behavioral patterns

  • Compliance with regulations

  • Records accomplishments


Building a case file what should be included

Building a Case FileWhat Should Be Included


Identifying information picture id

Identifying Information & Picture ID

Ohio State ID

  • Drivers license

  • State ID

  • Birth certificate


Social security cards

Social Security Cards


Homeless status psh

Homeless Status PSH

  • On the street

  • Emergency shelters

  • Transitional housing - coming from streets and emergency shelter


Homeless status th

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

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

Housing History

  • Why moved

  • Type of housing

  • Difficulties maintaining housing

  • Barriers

  • Housing needs


Disability status

Disability Status

  • Long-term, indefinite duration

  • Impedes ability to live independently

  • Disability could be improved with suitable housing


Disability status1

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

Consent Forms

  • Basic elements of consent

  • Informed choice

  • Overall experience

  • Voluntary participation


Educational vocational assessment

Educational & Vocational Assessment

  • Abilities

  • Interests

  • Personality


Employment history

Employment History

  • Gaps in employment

  • Positions held

  • Frequency of job changes

  • Skills

  • Strengths


Criminal background

Criminal Background

  • Criminal history as it impacts housing & employment


Psychosocial assessment

Psychosocial Assessment

  • Mood & affect

  • Cognitive functioning

  • Memory

  • Communication

  • Appearance

  • Mobility


Health assessment

Health Assessment

  • Medications

  • Medication log

  • Allergies

  • Illnesses


Service plan

Service Plan

  • Goals/objectives while in program

  • Drives service planning


Smart objectives

SMART Objectives

  • Specific

  • Measurable/observable

  • Attainable within time & conditions

  • Results-oriented

  • Targeted to the identified need & impact


Bloom s taxonomy

Bloom’s Taxonomy


Whose goal is it

Whose Goal Is It?

  • Participant agreement & responsibility

  • Central issue & priorities

  • CM - supporting role


Progress notes

Progress Notes

  • Refer to service plan

  • Describe progress

  • Interventions provided


Income verification

Income Verification

  • Amount of income

  • Sources of income

  • Proof of income


Incident reports

Incident Reports

  • What happened

  • When it happened

  • Others involved

  • Follow-up


Discharge summaries

Discharge Summaries

  • Reason for discharge

  • Income sources

  • Income amounts

  • Destination

  • Progress made

  • Referrals made


Charting legally sensitive situations

Charting Legally Sensitive Situations

  • Objectivity

  • Nonjudgmental description

  • Accuracy

  • Completeness

  • Legibility

  • Justify actions taken


Dissatisfied consumer

Dissatisfied Consumer

  • Utilize “quotes”

  • Don’t label - describe

  • History or crisis patterns

  • Attempts to satisfy

  • Choices provided made

  • Never characterize


Noncompliance

Noncompliance

  • How person refused to comply

  • Failure to provide information

  • Attempts to remedy

  • Review of procedures


Confidentiality

Confidentiality

  • HIPAA

  • Minimal access - need to know

  • Privileged communications


Peer review

Peer Review

  • Impartial review

  • Share expertise

  • Diversity of opinion

  • Provide suggestions


Quality monitoring

Quality Monitoring

  • Look at process and outcomes

  • Drive improvement

  • Accountability

  • Refine service delivery

  • Track integrity and effectiveness


Sample forms

Sample Forms


Questions

Questions


Documentation if it isn t written down it wasn t done

Coalition on Homelessness and Housing in OhioJonda Clemings, MSEd, LSW175 S. Third St. - Suite 250Columbus, Ohio 43215Phone 614-280-1984Fax [email protected]


  • Login