Documentation Basics

By cccldirector | Updated: June 16, 2024, 12:20 a.m.

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Documentation Basics

Most of our documentation is done in electronic format
Our Medication Administration and Physicians Orders
Our progress notes, behaviors, community integration, learning objectives, general health tracking etc...
Documentation Basics
ALL documentation is a legal and binding document

Documentation should tell the full story

Documentation must reflect facts only no opinions

ALL documentation is admissible in a court of law

"Your" documentation can be displayed publically in a court of law

"Your" documentation can become part of public record
 
"Your" documentation, if incorrect, could cost the agency thousands of dollars

On a daily basis and on each shift we document 
 Shift narrative (telling the story)

ADL’s (Activities of Daily Living)

Healthcare Notes (any health concerns)

Progress on Daily learning Objectives

Community Integration

Shift Narrative - Progress Notes
Telling the story
Chronological account of the shift you have worked with the individuals

Document facts only not opinions

Take Credit

If it is not documented "it didn't happen"

Shift Narrative - Progress Notes
Telling the story

Your documentation must tell the story or PAINT THE PICTURE  to anyone who reviews them and in most cases these are people who have never met you or the individual

Documenting ADL's
ADL = Activities of daily living
Bathing or showering
Washing Hair
Brushing Teeth
Toileting
Shaving
Daily Skin Check
Finger nails checked and or cut
Laundry

Objectives
All individuals have "Learning Objectives" in their plan
Learning to cook
Play a game
Value of money
Balancing a checkbook
Objectives
When documenting Objectives 
SCORING SYSTEM
 "completed independently"
"Various number of verbal promts "
"levels of assistance required" 
through "refused"

You can also write a note.

ANY time you write "refused" there MUST be an explanation noted.

Community Integration
Show how are individuals are interacting in the community they live in
Document Where they went
Wendy's, 
Wal-Mart
Bank
Festival (where and what)
Dance (where)
etc...

In the comment section you can write any pertinent information if needed.

Individuals bowel tracking if required

Adaptive Equipment Daily Cleaning / Monthly Maintenance

Diet Tracking (calorie counts),

Health Tracking in Therap

On a daily basis and on each shift we document
Bowel Tracking
Many of our individuals have Dr. ordered bowel tracking to ensure they are healthy and bowels are functioning as needed. 
You will note 
size
visual description if required
any irregularities from normal

For those independent individuals it may be a simple as documenting what they report to you on the tracking login Therap.

Adaptive Equipment Logs
Wheelchairs, walkers, helmets, bath seats cpaps etc...
ALL medical adaptive equipment has daily and monthly service/cleaning requirements

The adaptive equipment logs will have detailed specific information written in them inTherap instructing you on what needs to be done daily and monthly to maintain the equipment in good working order. .

Diet Tracking
Tracking calories, sodium, fluids etc... per Dr. Order
Under Health Tracking in Therap
There is a "Intake Elimination"  menu

When documenting special diets you must include what 
was consumed as well 
as the values that are being tracked

Cheeseburger - 400 Calories
or
Hotdog and chips - 300 grams sodium

Health Tracking 
Part of health tracking is the individuals healthcare notes within their progress notes in Therap.
Dr. Appointments
Colds
Fevers
Falls

Anything that effects their health

Health Tracking 
Many sub menu's under HT in Therap
You will learn more about the Health Tracking capabilities in Therap during your Therap specific documentation training such as

Appointments
Seizure logs
vital signs
etc...

Documentation Times
If you are working a shift that crosses the midnight hour you will have to break out your documentation by calendar day.

ie: 10:00pm to 11:59pm
then
12:00am to 6:00am

BASIC PRINCIPLES OF CHARTING
"Documentation"
The " How" - Format

The "Who" - Identification

The " What" - significant event

The How "Format"
Always document in third person.

ie: This Staff noted, This Staff observed, etc...

Never use another individuals name in progress notes

Housemate MH, Friend DG, staff KW

The Who"Format"
Always identify guests or family never just say mom or sister

Mom Mary, Sister Sue,  etc...

The What "Format"
Document FACTS ONLY never hearsay

ie: Bob fell (wrong), 
Staff KW reported Bob Fell (correct)
or
This staff observed Bob fall (correct)
or
Housemate DG reported to this staff Bob fell

The How "Format"
Document FACTS ONLY never opinions

Mary was happy today (wrong)

Mary appeared to be happy today as she was dancing and singing and smiling. (correct)

The How "Format"
Document FACTS ONLY never opinions

Billy slept all night (wrong)

Billy appeared to rest peacefully through the night (Correct)

The How "Format"
When documenting on paper

ALWAYS USE BLACK INK

NEVER USE WHITE OUT

If you make an error simply draw a line through the error initial and begin on the next line with the corrected documentation.

The How "Format"
There must be documentation for every shift every day, even if nothing happened.

Example: If the individual does not require safety checks on the night shift  It may be a simple as noting "staff SC reported the individual was in their room upon arrival and appeared to remain there through the night"

The WHO  "identification"
Use the individuals name in their own documentation

Never use other individuals names in documentation only initials or relationship such as housemate MH

Always identify others such as Mom- Mary or Dad - Scott

The What – (significant events)
Tell the story and take credit for what we do to support our individuals

Our documentation MUST support the services we are providing on a daily basis.

The What – (significant events)

Chart what you (staff) are doing.

Take credit!

Show the state you are needed by charting the things you are doing!

The What – (significant events)

What are your teaching

How are you assisting

How are they responding

The What – (significant events)
Each time an individual has visitors or telephoned

Response to treatment and medications

Advice / recommendations given to individual (Be careful and document)

Examples of significant events
The What – (significant events)

Medical Appointments, physician, attorney, family visits

Refusal to cooperate (treatments, medications, objectives etc.)

Nights that are considered uneventful – “individual appeared to rest peacefully through the night”

Significant Events
The What – (significant events)

“Individual was up 3 times during the night to use restroom - staff woke and redirected back to bed”

Any safety checks provided to individual per ISP plan during the night.

“Safety check at 1am and 3am” “No concerns”

Document, Document, Document
The What – (significant events)

Overnight awake staff - Document any events or tasks for individual such as housekeeping, laundry, including continence checks or “changed depends or changed sheets”

Document, Document, Document
The What – (significant events)

Outings into the community where did they go

Any general health concerns

Social activities

Behaviors outside the norm

The What – (significant events)
If it is not documented ....
"It just didn't happen"
Bottom line....
The What – REMINDERS

Remember facts only.... No Opinions

Document in third person.... this staff

Never use other individuals names 
use only initials  and/or relationship
Housemate,  MM etc..

The What – REMINDERS

Identify guests......   Mom - Mary, Pastor - Bill

NEVER document hearsay......
If you didn't witness.....

Bob fell (wrong) 
Staff EL reported Bob fell (Correct)

Nursing Short Hand - Abbreviations
As we are not nurses be careful when using abbreviations or nursing short hand.

There are only a few abbreviations that we deem acceptable when documenting as a DSP with the agency.

Nursing Short Hand - Abbreviations
The reason for this is if you are not fully competent in nursing short hand errors in abbreviations may tell a completely different story than intended. 
Nursing Short Hand - Abbreviations
c = with (c with a line over it)
 BID = 2 x a day 
TID = 3 x a day 
QID = 4 x a day

Common Short Hand
_
Nursing Short Hand - Abbreviations
s = without 
a = before 
p = after (post) 
hs = hour of sleep, bedtime (2100) 
PRN = as needed 
c/o = complaining of 
noc = Night 
NKDA = no known drug allergies

Basic abbreviations that are acceptable. 
Nursing Short Hand - Abbreviations
Again remember there are only BASIC abbreviations that are acceptable to use. 
L1MA Training
Nursing Short Hand - Abbreviations
If you do not feel completely confident in using these abbreviations write everything in long hand.

We need to make sure the proper story is told and abbreviation errors can completely change the story. .

Writing in long hand
Do not ever write with abbreviations,
 spell out what you are documenting.

ie: Went to a rest. for dinner (wrong)
Went to a restaurant, Denny's for dinner (correct)

Writing in long hand
Individuals did not comp. his meal (wrong)

Individual did not complete his meal (correct)

We never want abbreviations to be misunderstood.

Write with Understanding
Auditors and other professionals MUST know exactly what you are saying.

They will not be present at the time you document.

DO NOT leave anything to guess work.

Write with Understanding
People reading your documentation must be able to understand the entire picture.

Most reviewers will have never met our individuals or been in our homes.

Document the clear story so anyone will understand the  full and true picture.

CONFIDENTIALITY
All records are confidential

Information should not be released without proper communication and approval by agency management.

In most cases releasing protected health information (PHI)
requires a HIPAA compliant written and signed authorization.

CONFIDENTIALITY
Information can only be given to:

Individuals legal guardian
with written proof of current guardianship.

Personal attorney of the individual 
With a signed HIPAA compliant release form

CONFIDENTIALITY
Information can only be given to:

Physician or authorized medical personnel 
With a HIPAA compliant business associate agreement

Credentialed Abuse and Neglect Investigator
Credentialed State Reviewer
Credentialed Service Coordinator

CONFIDENTIALITY
Facilities are required by law to document dates, nature, purpose and recipient of any medical records disclosed.

Many entities are required to have a HIPAA compliant release form.

ROI – Release of Information has become a billion dollar industry.

CONFIDENTIALITY

Legal action and stiff penalties can result when PHI is improperly released.

When PHI is improperly released you and the agency can be held accountable
This includes jail time and significant financial penalties
When in doubt, don't give it out.
Community Intigration
Involvement in their church
Shopping
Dining Out
Going to work
Socializing
Taking vacations
Sporting events
Theater

It is very important that our individuals enjoy the same involvment in their community as their non-disabled counter parts. 
Community Intigration
What church did the attend...
What stores did they shop at...
What restaurants did they dine at...
Where did they go for work...
Where did they socialize ...
What sporting event...
What theater...

When documenting their community time give specifics
Community Intigration
You want to make sure you paint a very clear picture of when and how they enjoyed time within their community. 
Remember our documentation must tell the whole story very clearly even to someone who has never met our individuals. 
If it is not documented, 
it just didn't happen.

Documentation No, No's
Meaningless charting ie:  it was a beautiful day
Documentation should include "facts" not opinions 
Subjective Marks !!!, ALL CAPS, underlining a statement
These subjective marks change the tone of the statement.

Documentation No, No's
Pointing fingers ie: Staff A did not shower Bob today, so I had to 
Drawing conclusions or opinions such as

Bob had a bad day at work.... No No

Bob was written up at work for sleeping....Yes Yes

Documentation No, No's
Bob came home from work mad.... No No

Bob came home from work and appeared mad because he was hitting things, yelling at staff etc... Yes Yes

Altering or deleting documentation once it is complete
Documentation No, No's
Altering or deleting documentation is illegal and punishable by law. 
REMEMBER
 you are creating legal and binding documents when charting.

THERE ARE VERY FEW THINGS WE  STILL DOCUMENT  ON PAPER
However in the event of the need to document on paper in a power outage those notes would still be transcribed into Therap once the power is restored. 
 Individuals Mileage Logs

Emergency MAR
Emergency Progress Notes 
in the event of a power outage.

Individuals Mileage Logs

Every Trip
Tracked Monthly
Required for Billing

Power Outages, Internet Issues
There is an individual "Small Book" for every individual located in their home.   In the event you can not access the software for any reason.  There are paper back ups in their small books for progress notes and MAR's. 
Power Outages, Internet Issues
You can document on the paper forms until the outage is corrected then transfer it into THERAP once the access is restored.
Power Outages, Internet Issues
For the paper MAR you can enter data into Quickmar ONLY if the access comes up within the same calendar day. Otherwise it will have to be corrected by the office staff. 
Documentation Basics

Documentation Basics Quiz

Documentation Basics

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