Chesapeake CSB Quality Assurance Training. Learning to Document for Compliance and Quality Of Services. Table of Contents . Introduction – Why document? The Basics Assessment Emergency Medical Service Plan Progress Notes High Risk Discharge .
Learning to Document for
Compliance and Quality
“If writing must be a precise form of communication, it should be treated like a precision instrument.It should be sharpened, and it should not be used carelessly.”Theodore M. Bernstein
Protects the service recipients, staff, and agency :
a) Provides critical emergency information
b) Allows other team providers to help
c) Maintains licensure
d) Supports payment for services as it is written - proof of the great work you have done
e) Enhances quality of treatment
a) should be minimal
b) indicate that the information
documented regarding past dated services
or to correct an error is documented and
signed with the current date so as not to
appear fraudulent, e.g.
Example: “As I review my notes I see I forgot to document….”
*Note: Also refer to Credible Manual on “M” drive
for EMR error correction/addendum SOP.
c) include why the entry is late
d) any note > 30 days past the service is TOO late
e) NO late entry in response to threatened
f) never make a late entry when document has already been copied and given out
issue or question was not addressed.
Individualized Service Plan
desired outcome flows from beginning to end
Have you specified:
Allergies to medication?
Emergency Medical Contacts?
PCP information: Who, how to contact, OK or refuse to have contacted? (Do not forget Client Authorization if OK)
Checked all Health Habits or marked “None”?
Updated as arises and/or annually on EMR Medical Profile?
engage individual in requested services
C) ISP goals addressed during contact
Avoid subjective, critical statements:
Service recipients have the right to inspect their records and request amendments (human rights regulations, HIPAA regulations,
VA Privacy Act)
Be concise; stick to the facts.
of completing ADL skills to maintain
current living situation.”
individual has been in the hospital for
work on my issues about rejection.”
Exhibits inappropriate behavior that often results in intervention by mental health or judicial system
*In order for a person to meet the criteria for continued CM they must meet two or more of the above.
the team matters pertaining to
the individual via note and EMR warning, to do, and/or instant message, e.g. “(Individual’s Name) *revoked authorization to disclose information for family member, or was hospitalized or reports medical problem or admits to abusing substances, and/or what team members would need to know to provide quality services for the individual. Documenting the outcomes of phone calls and meetings also keeps the team informed.
*Refer to Credible EMR Manual, “M” drive, “SOP for Revocation of ROI”
If the individual is noncompliant to the agreed upon ISP goals/services document their noncompliance and the plan for follow up to address the noncompliance in an encouraging manner.
ideation, plan and/or intent.
relationship conflict (very common)
Document at end of assessment and on
ISP recommended interventions and referrals to address these situations to decrease the likelihood of such behavior. This is to include focus upon the individual’s strengths.
Examples of such referrals/interventions:
discharge plan and criteria.
a) reason for discharge
b) progress made
c) individual’s/family’s participation in discharge
d) individual’s level of functioning at discharge
e) discharge medications, if applicable
f) discharge diagnosis, if applicable
g) discharge referrals/recommendations
h) individual’s date of discharge and date
summary is written
i) signature of responsible staff