Menu of Opportunities Human Services Documentation Menu of Opportunities Human Services

What is its purpose? Monitor progress Communicate specific information If you don’t document-IT NEVER HAPPENED. Remember: What you write will become a part of a person’s permanent record and it is a legal document.

Documentation at Shangri-La House logs Medication Records Progress Notes Incident Reports Data Collection Financial Records All documents should use objective language. The goal is to write clearly, in a way that avoids any confusion or misinterpretation.

Types of Language Do use descriptive language Describe EXACTLY what happened. Use only FACTS. Be precise, leave no room for interpretations. Avoid Subjective Language Vague, not specific Includes emotions and personal judgment Easy to misinterpret

Comparison Subjective Descriptive/Objective Observable Non-observable Measurable Vague Precise General Specific Judgmental Based on facts Not able to Count Countable Uses Labels States Action Easy to misinterpret Uses your senses Not easy to misinterpret

Writing Reports When writing reports answer these questions. Why? What lead to the incident? What was the reason the individual gave? Who? Was present? Who was involved? What? Happened? Was going on? What was the environment like? How? In what way did the occurrence happen? How did the person behave/act? When? What time of the day? Date? Where? Bedroom? Event? Outside? Location?

Writing Reports Continued Show Sequence In many situations it is important to understand the order of events. Example: 1. 2. 3. OR 9:00am 11:00am 1:00pm Show Comparisons Show the difference between a person’s typical behavior and what is not typical.

Are the following Statements objective? *Measurable/Observable. Ann was in a bad mood this morning. Dawn was very pleased with the card her mom sent. Bill fell at some time and had a huge bruise. Susie completed her laundry four times this month. George yelled at staff and threw a big tantrum. Restate the above sentences using objective language, remember to use who, what, when, where, why and how?

Rules for Written Documentation Write clearly, using dark ink or type. Date each sheet/entry with month, day and year. State AM or PM Sign your name and title Be sure the individuals name is on each document. If you make an error draw one single line through the error and intial.

Incident Report: General Guide Complete and submit report within 24 hours. Write legibly using black pen or type the report. Complete entire form, including as much detailed information as possible. The state who knows the most about the incident should complete the form. Provide accurate dates and time of incident. Complete all elements of consumer information. Make sure to only use first names of other individuals mentioned. Be sure to document any injuries that occurred.

Incident Report: General Guide Continued… Describe the incident: provide the full story from start to finish. Include as many specifics as possible (timelines, define behaviors, and identify those who were involved.) If necessary continue on a separate sheet of paper and write “see attached” on the form. Be sure to attached additional paper. Keep all information factual; leave out persona judgments or opinions about the incident.

Conclusion