Documentation

Documentation is an important part of the Direct Support Professionals responsibilities. The documentation that employees complete is used for many purposes:

·  To create a record of important situations, incidents and events;

·  To provide a base of information from which decisions can be made regarding medication or person centered support changes;

·  Show the progress and successes of the individuals

·  To provide proof of the services that we are providing and receiving payment for;

·  And many others.

Documentation must provide an accurate and objective account of what and when events occurred, as well as identify who provided the care. It should present a clear picture of an individual’s needs, the staff’s actions, and the individual’s response. Good documentation has five important characteristics. It should be: (1) factual, (2) accurate, (3) complete, (4) current (timely), and (5) organized. Documentation should NOT be a subjective account of events from the staff’s perspective.

Here are some tips to remember about documentation:

·  Documentation for the shift should be done during the shift. Do not leave it to be done the next day, the next time you come in. Complete it before you go home.

·  Use black or blue ink.

·  Write legibly. If it can’t be read at a later date, it is if no use.

·  Make sure the individual’s first and last name is on every page of documentation.

·  Make sure each page is dated with month and year. Progress notes and health progress notes must have a full date – Month/Day/Year as well as the shift you are writing about.

·  Progress Note entries must include your signature with full first and last name and your title. (i.e. Mike Schmidt, DSP)

·  Make sure the documentation clearly explains what you are trying to record. Imagine that someone who may not know the individual is reading the entry. Would they understand what the situation was?

·  NEVER assume that because you recorded something in a Progress Note or a Health Progress Note that everyone knows about it. Make sure to communicate any important information to your supervisor, such as incidents, health concerns, etc..

·  Be sure to read the communication log at the start of each shift, to be up to date, and finish each shift by writing in the communication log, to update the next shift.

·  The documentation you do becomes a legal document and is in the clients permanent file.

·  HIPAA regulations apply to almost all of Zumbro documentation. The Communications log is not a legal

document and is not under HIPAA regulations.

It is essential that documentation is completed promptly and that it is thorough. Some examples of documentation that you must complete on each shift include:

Progress Notes –

Progress Notes provide a description of how and what the individual had done throughout your shift. There should be a progress note written for each shift. They should be written with full sentences, contain only approved abbreviations be free of opinions or slang terms, and clearly outline the details of the day for that particular individual. They should also never contain other individual’s names; we can use terms like peer or housemate rather than their names. Below is an example of a well written Progress Note:

6/2/2016 / 3-11pm / Huckleberry reported that he had a conflict with a coworker today at his day placement. Staff advised Huckleberry to speak with his job coach about the conflict when he arrives at work tomorrow. The day placement staff was notified of the situation by phone at 4:00pm. Huckleberry went to bowling and watched a movie before heading for bed at 9:30 pm.
John Jones, DSP …………………………………………………………………………………………......

Health Progress Notes -

Health Progress Notes are similar to progress notes, except, of course, they address health related information. Although it may not be necessary to write in the Health Progress Notes every day, it is important to be sure that health information is recorded whenever it is applicable. It is important in Health Progress Notes to state complaints of illness or injury or other information very clearly and objectively. If a individual has an ongoing health concern, such as bronchitis, Health Progress Notes should be completed every day until it is resolved. Below is an example of a well written Health Progress Note:

6/2/2016 / 3-11PM / Huckleberry reported to staff upon returning home from work that he felt like he had a fever. Huckleberry’s temperature was taken at 3:30pm and it was 101.3. Zumbro House nurse was called and adfvised to give Tylenol as directed in the standing orders. Gave 2-500mg tablets of Tylenol at 3:45pm. Huckleberry reported at supper, approximately 5pm that he felt much better. His temperature was taken again at 5:30pm and it was 98.6.
John Jones DSP………………………………………......

Data Tracking Sheets –

These sheets are where we keep track of target behaviors and current goals. It is important that target behaviors are documented accurately, as this data is compiled and often presented to the physician or psychiatrist to make decisions regarding medications or treatment plans. Target behaviors are tracked by indicating a (Y) - yes the target behavior was displayed during the time period, (NO) - no the target behavior was NOT displayed during the time period, or (LOA) – the individual was on Leave of Absence. See the first example below. The goals/outcomes are areas decided on by the individual and their team where they would like to gain more skills and independence. This documentation is compiled and analyzed to monitor the individual’s progress in those areas. The second example below shows a goal tracking sheet where (YES) indicates the individual completed or met a task, (N/A) indicates that it was not applicable to offer the individual the task that day, and (NO) indicates that the individual was offered the task but refused to complete it or did not meet the goal.

Monthly Data Summary / Name: / Huckleberry Axelrod
Target Behaviors / Month: / April / Year: / 2016
1 / 2 / 3 / 4 / 5 / 6 / 7 / (Y) - yes, target behavior was displayed during the time period
(NO) - no, target behavior was NOT displayed during the time period
(LOA) - Leave of Absence
Was Huckleberry Safe or Unsafe today / Verbal Aggression (threatening, yelling, cursing, name-calling) / Inappropriate Sexual Behavior (sexual talk, touch, staring at breasts or genitals of others) / Defiance (purposefully going against house rules or staff direction) / Elopement (leaving Zumbro House property without approval) / Property Destruction (throwing objects, slamming doors, hitting walls/doors, etc)
AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM
1 / LOA / LOA / LOA / LOA / LOA / LOA / LOA / LOA / LOA / LOA / LOA / LOA
2 / S / S / NO / NO / NO / NO / NO / NO / NO / NO / NO / NO
3 / S / U / NO / Y / NO / NO / NO / Y / NO / NO / NO / Y

On the back of the sheet record the “What and Why” of the “Yes” answers and/or why he was unsafe during this time. For example “Huckleberry refused to complete his daily chore; staff provided 4 prompts. He then swore and slammed his bedroom door.

Monthly Data Summary / Name: / Huckleberry Axelrod
Tasks / Month: / April / Year: / 2016
1 / 2 / 3 / 4 / 5 / 6 / 7 / (Y) = individual completed task or met goal
(N/A) = task was not offered to individual that day
(NO) = individual was offered task but refused to complete or did not meet goal
Huckleberry completed his designated daily chore without staff prompting. / Huckleberry will plan and prepare a meal a minimum of once per week. / Huckleberry will complete the entire laundry process once per week with one verbal prompt or less. / Huckleberry will plan and initiate an activity with a peer twice per month.
(LOA) = Leave of Absence
Comment below regarding variables and Changes (e.g. drugs, dose, programs, level, etc.)
AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM / AM / PM
1 / Y / Y / N/A / N/A / N/A / N/A / N/A / Y
2 / Y / Y / N/A / Y / N/A / N/A / N/A / N/A
3 / NO / Y / N/A / N/A / N/A / NO / N/A / N/A

Again note on the back of the sheet any details about interfering behavior. Example on April 1st you may have noted “Huckleberry planned and initiated a walk around Lake Calhoun with a friend from Oliver house,” to explain the “Y”. On the 3rd, “Huckleberry required 4 verbal prompts to complete laundry.” Tells why he got a no for his laundry this week,

Medication Administration Records –

The Medication Administration Record is where we document what medications have been administered to the individual. You will learn all of the details regarding this type of documentation when you review Medication Administration Policy and Procedures.

Sleep Charts –

Sleep charts are kept for each and every individual, and reflect the individuals sleep patterns. Many times a change in sleep pattern or frequent difficulty sleeping can be indicator that something else is going on with the individual; they may be sick, anxious, depressed, upset, or even experiencing an increase in psychiatric symptoms. Please check the individuals protocol for required checks, supervision, prompting for toileting, etc. .

Incident reports –

Incident reports are completed any time there is an incident. What does that mean? An “incident” occurs any time there is a situation that is out of the normal routine, had or could have had a negative effect on the individual, their housemates, the community, etc. ,for example any time the individual attempts to elope, and many other situations that may involve a target or interfering behavior. The incident report is available on the Zumbro House website as an email me form. The report should be completed and submitted electronically, which will be automatically forwarded to the Lead, the Program Director and the Director of Program Services. There are more detailed instructions on incident reporting at each site. It is essential that the incident report get completed during the shift in which the incident occurred. It is never acceptable to put it off until the next day or the next time you are scheduled. For certain incidents, Zumbro House is required to notify members of the individual’s team within 24 hours. This email with the incident report is what alerts the office to the situation and that notification process is started at that time. If you are ever unsure about if an incident report should be completed, contact your Lead Counselor for guidance.