Documentation of Services Tip Sheet Progress Notes Documentation of Services Tip Sheet Washtenaw County Community Mental Health

Overview Keeping track of what is happening in the life and services of the person you support requires keeping records. While providing direct services may be the core of your responsibility, effective documentation tracks and details the needs, services, goals, and progress of the person served. The quality of your documentation also impacts decisions that are made about the services the person is receiving, ensures all members of the care team communicate important details about those services and ultimately affects the person’s quality of life. Washtenaw County Community Mental Health

Overview, Continued Any service paid for by state/federal funding can/will be audited. Centers for Medicare and Medicaid Services (federal) and Michigan Department of Health and Human Services (state) will require proof a specific service occurred when auditing. Documentation (progress note, daily log) is a way to show: What service was provided (paid for) How long a service/shift was provided By who a service was provided (must be an appropriately trained/credentialed staff) If this information is not fully provided, money paid out for that service will be taken back. Detailed documentation is essential for quality care, good communication, and to prove state/federally funded services. Washtenaw County Community Mental Health

Why is documenting services important? Progress notes are the central aspect of a person’s health record; a place where staff document the care they deliver All relevant details should be documented for a person’s diagnosis, clinical state, and daily activities that occurred during a shift Demonstrates medical necessity: justifies why the individual needs the services Provides a foundation for future services and for alternate approaches Compliance with insurance company requirements: clearly documents encounters/proves services provided for billing purposes Washtenaw County Community Mental Health

Why is documenting services important? Continued Reduces duplication of services provided between co-workers Can be subpoenaed and read in Court of Law Used to prove services occurred for audit purposes Reminds all of what has previously occurred with the person Tracks progress with goals Aids communication between co-workers When appropriate, aids communication with natural supports and family members Washtenaw County Community Mental Health

What gets documented? What you actually did: attended appointment, cooked with client, worked on sensory goal, administered meds, prompted to complete household chores, etc. Progress on treatment plan (IPOS) goals Observable facts Information the person themselves state Unusual incidents and accidents involving the person Communication with other service providers The health status of the person, including current health planning and management, and medication management Washtenaw County Community Mental Health

What does not get documented/what you should not include? Opinions, judgments, or unproved statements Information about another client Slang/jargon Abbreviations Washtenaw County Community Mental Health

Helpful Tips If you didn’t document it, it didn’t occur Notes must be accurate, easy to read, complete and timely Write for an audience Notes should be connected to the client’s individualized treatment plan Do not use white out or scribble anything out If you make a mistake, cross it out and put your initials by it Always include the following information: date, times, client’s name and signature of staff Washtenaw County Community Mental Health

Example: Residential Setting Washtenaw County Community Mental Health

Example: Non-Residential Setting Washtenaw County Community Mental Health

Reminders Residential Setting= non-licensed CLS settings and licensed residential settings Non-residential settings= skill building, supported employment, ABA, respite, etc. Do not combine multiple clients on one progress note Include client’s name and ID # Include the times that services were provided to client (include “AM/PM) Check boxes are not enough- always add staff observations/goals worked on Always sign-off and date the progress note Washtenaw County Community Mental Health