1. Menu of Opportunities Human Services
Documentation
Menu of Opportunities
Human Services

2. 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.

3. 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.

4. 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

5. 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

6. 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?

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

8. 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?

9. 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.

10. 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.

11. 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.

12. Conclusion