Ongoing Learning and Documentation
Instructions: Supports must be documented each time they are provided. This can be accomplished through a narrative description of the supports provided, the person’s response and how improvements will be made to enhance success. A checklist may be used along with notes. The checklist contains the support activities, the frequency and the initials of the DSP providing supports. When using the checklist along with routine notes, the notes will touch on various supports across the billing period. The frequency of documentation for skill-building should appropriate to the skill, the frequency of practice and agency guidelines. It is important that no support be submitted for reimbursement without a note that summarizes the support, person’s response and related efforts to improve how the support is provided.
There are six templates provided for use in documenting supports. Three logs and three checklist templates are available. These tools may be used in combination to adequately document the supports provided.
The three checklists:
- The support checklist may be used in combination with ongoing notes to confirm that all supports were provided as agreed.
- The periodic support checklist includes the needed elements for the use of periodic support hours when alternate plans are cancelled.
- The safety support checklist provides a way of documenting supports related to health and safety.
The three logs for ongoing notation:
- The support log contains a chronological accounting of events.
- The learning log provides a means of documenting learning related to routine supports that do not include skill-building.
- The skill-building log provides the elements that must be documented when skill-building is being attempted.
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Support Checklist for ______ISP Dates: from ______to ______Month: ______Year: ______Provider: ______Service: ______
Morning (__am to ___pm)
Supports / when / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
[activity]
[activity]
[activity]
[activity]
Afternoon(___pm to ___pm)
Supports / when / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
[activity]
[activity]
[activity]
[activity]
Evening(___pm to ___pm)
Supports / when / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
[activity]
[activity]
[activity]
[activity]
Overnight(___pm to ___am)
Supports / when / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31
[activity]
[activity]
[activity]
[activity]
Key (The use of any code requires a log entry):
Initials = support provided, Printed Name: ______Initials: _____ Date: ______
Circled initials = support provided/notation in log,
C = chose not to participate, Printed Name: ______Initials: _____ Date: ______
A = individual not present,
I = incident Printed Name: ______Initials: _____ Date: ______
O = other
VA ISP Checklist rev. 4.1.15 Printed Name: ______Initials: _____ Date: ______
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Name: Medicaid No: / Periodic Supports ChecklistOutcome(s) addressed
Date / Reason for use / Periodic Support Activities (See the PC ISP Part V: Plan for Supports for support instructions.) / Time / Total hours / Initials
FROM / TO
DSP/Supporters Printed Name / Initials / Date / A signature page must be kept on site or in each record to correspond with all initials provided.
Support Log (In addition to a monthly summary of all periodic supports, note any unusual circumstances and related support.)
Name: Medicaid No: / Safety Supports Checklist
Outcome(s) addressed
Day/Month/Year
Safety Support Activities
(See the PC ISP Part V: Plan for Supports for support instructions.) / Initials / hours / Initials / hours / Initials / hours / Initials / hours / Initials / hours / Initials / hours / Initials / hours
Total hours
DSP/Supporters Printed Name / Initials / Date / A signature page must be kept on site or in each record to correspond with all initials provided.
Support Log (In addition to a weekly summary of all safety supports, note any unusual circumstances and related support.)
Support Log for ______
Date / Details
[Enter date support was provided] / [Enter details of contact or activity, signature and date of completed entry]
Learning Log for ______
Date
and Signature / What did the person do? (What, where, when, how long?) / Who was there?
(name of people
supporting the person, friends and
others) / What did you learn about what worked well? What did the person like about the activity? What needs to stay the same? / What did you learn about what didn’t work? What did the person not like about the activity? What needs to be different?
[Enter date and signature] / [Enter details about the activity] / [Enter who was present] / [Enter description of what worked well and what should stay the same] / [Enter description of what didn’t work and needs to be different]
Skill-building Log for ______
Outcome / [Enter the desired outcome]
Support Activity / [Enter the support activity]
Date
and Signature / What did the person do to practice the skill?
(What, where, when, how long?) / Who was there?
(name of people
supporting the person,
friends and others) / List what you saw that shows the person is learning and what you did to help. / List what the person liked and what might need to change.
[Enter date and signature] / [Enter details about the skill-building activity] / [Enter who was present] / [List what the person did to show learning and how you helped them learn] / [Enter description of what the person liked and what needs to be different to enhance learning]
This ISP belongs to: ID# _____ISP Start: End: ______Revision: ______
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