Report Writing And Documentation

Professionalism There are several reports and items of documentation that need to be completed by treatment parents to track the youths progress, document information needed for licensing and medicaid requirements Caseworkers and other consumers are more willing to place youth and see you as a professional treatment provider when these items are: »1. On Time »2. Complete and Accurate »3. Good Quality of Work

Reports Reports that are required of treatment foster parents are: –Monthly SDS ( Skills Development Summary) Timeliness – due by the 5 th of every month Complete and Accurate – all information filled in completely with appropriate signatures. Quality of Work- report should be written with detailed and specific information in the appropriate places. Request feedback monthly to make sure these are meeting medicaid requirements and information useful in tracking youths progress and the planned interventions to be used the following month.

Reports: Monthly SDS Goal # __ - to be taken directly from treatment plan in the same order even if goal is discontinued or resolved. Example: Goal #1 – Increase Acceptance of Authority Presenting Problem- why the youth needs treatment Example: (Youth) has a tendency to argue with adults when told “no” and refuses to be compliant when given rules or directions. Progress- Identify strengths, approximations, shaping or chaining of behaviors that are improving in frequency, duration, or intensity. Identify behaviors that there is more improvement needed and how that is going to be attained. –Example: ( Youth) has shown improvement this month by completing tasks, both daily and spontaneous without arguing. He/She is able to recite the steps to following instructions, accepting criticism, accepting “no” and disagreeing appropriately. ( Youth) still argues, stomps feet or cries when told “no” or given a consequence, requiring prompting to control emotions and frequently earning additional consequences. We will continue to role play controlling emotions daily and provide additional reinforcement for the times he/she is able to do this on their own. Continued Need for SDS – the skills the youth still needs to learn to be able to resolve this goal area. –Example: (Youth) continues to need to learn to say “okay”, control his’/her emotions, and avoid arguing on a daily basis

Insert Monthly SDS Worksheet in Manual

Incident Reports Incident reports are required by licensing, DCFS and JJS as well as other consumers to document incidences such as serious youth behaviors, ( I.E. running away, suspension, aggression, property damage etc.), injuries to youth, reports or allegations of abuse, and other items specified on the form. All subsystems should trigger an incident report. –Timeliness – Abuse, injuries must be completed within 24 hours. All others must be done within 72 hours. –Complete and Accurate – All information must be filled out and accurate. –Quality of Work – The incident should be written behaviorally specific complete with addresses of location, times of events, names of individuals involved. The documentation should not include judgment calls, slang, or derogatory terms other then items directly quoted.

Insert Incident Report

List of Documentation Fire Drill Logs Medication Logs Youth Accounts and Receipts CHEC/ Dental/ Mental Health Morning Report/ contacts and activities Family Meetings Documentation of Daily SDS on motivation system tool ( point cards, etc.) Other Tracking Sheets: School notes, Job notes, and Home Visit Notes

Documentation will be checked by Consultants and Caseworkers. Meet with your consultant and go over Each item in the Reports and Documentation Notebooks.

Paperwork and Documentation Timeline Yearly –CHEC, licensing paperwork, consumers Six months - Dental, Insurance papers, first consumer Quarterly - Staffings, Quarterly Reports, YOQ’s Monthly - Youth Accounts/Receipts, Monthly SDS, Morning Report and Contacts, Med logs turned in, fire drills Weekly - Contact with consumers, weekly sheets Daily - Point cards, School Notes, documentation of medications, documentation of daily contact, activities As Needed - Incidence Reports, Subsystem Worksheets

Turned into Consultant Point Cards School Notes or Job Notes Home Notes Monthly SDS Youth Account/ Receipts Incident Reports Subsystem Worksheets Morning Reports CHECS/Dentals/ Therapy Copies of Report Cards, Court information and Staffing information and other items you would like kept in Youth File at office

Return to Office Billing Statement Other * Everything else should be kept in youth file at home and out of home folder or in documentation notebooks.

Due by the 5 th : To Consultant: - Monthly SDS - Point Cards or SDS –YOQ’s –Copy of Youth accounts and receipts –Copy of Youth medication logs To Diane: - Billing Statement

Report Writing And Documentation This training presentation is available for download at: © 2007 Utah Youth Village.