Documentation - If it Isn’t Written Down - It Wasn’t Done

Documentation -

If it Isn’t Written Down -

It Wasn’t Done

Jonda Clemings, MSEd, LSW

Outline for Training

• What should we document?

• Why should we document?

• How should we document?

What Should We Document?• Functional limitations & abilities• Barriers that led to homelessness• Program adherence• General observation

Why Should We Document?

• Professional ethics• Guarding against

liability• Social responsibility• Consumer benefits• Requirement

How Should We Document?

• Precisely• Objectively• Avoid documenting outside

scope of practice– Diagnosing

Documentation Guidelines

• Follow agency policy• Permanent ink• Avoid backdating• Chronological order

Documentation Guidelines

• No blank space• Sign, credentials, date• Legible, correct grammar• Avoid clichés

Documenting Guidelines

• Be specific, factual• Progress or lack of • Document only

services you provide

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On-Going Assessments

• Assess• Review & revise

regularly• Plan• Implement• Discuss strengths,

weaknesses, and obstacles

Maintaining a Case FileWhy is it Important?

• Quick access to information

• Enhance service delivery

• Continuity of care• Record of progress

and goal attainment

Maintaining a Case FileWhy is it Important?

• History of behavioral patterns

• Compliance with regulations

• Records accomplishments

Building a Case FileWhat Should Be Included

Identifying Information & Picture ID

• Drivers license• State ID• Birth certificate

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Ohio State ID

Social Security Cards

Homeless Status PSH

• On the street• Emergency shelters• Transitional housing -

coming from streets and emergency shelter

Homeless Status TH

• Same as PSH - and• Evicted within a week - no

subsequent resources• Discharged within a month -

no subsequent resources• Fleeing domestic violence - no

subsequent resources

Chronic Homeless Status

• Unaccompanied individual• Disabling condition• Living on streets or

emergency shelter• 1 continuous year

homeless or 4 episodes of homelessness in 3 years

Housing History

• Why moved• Type of housing• Difficulties maintaining

housing• Barriers• Housing needs

Disability Status

• Long-term, indefinite duration

• Impedes ability to live independently

• Disability could be improved with suitable housing

Disability Status

• Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use

• Written documentation must come from credentialed professional

Consent Forms• Basic elements of consent• Informed choice• Overall experience• Voluntary participation

Educational & Vocational Assessment

• Abilities• Interests• Personality

Employment History

• Gaps in employment• Positions held• Frequency of job changes• Skills• Strengths

Criminal Background

• Criminal history as it impacts housing & employment

Psychosocial Assessment

• Mood & affect• Cognitive functioning• Memory• Communication • Appearance• Mobility

Health Assessment

• Medications• Medication log• Allergies• Illnesses

Service Plan

• Goals/objectives while in program

• Drives service planning

SMART Objectives

• Specific

• Measurable/observable

• Attainable within time & conditions

• Results-oriented

• Targeted to the identified need & impact

Bloom’s Taxonomy

Whose Goal Is It?

• Participant agreement & responsibility• Central issue & priorities• CM - supporting role

Progress Notes

• Refer to service plan• Describe progress• Interventions provided

Income Verification

• Amount of income• Sources of income• Proof of income

Incident Reports

• What happened• When it happened• Others involved• Follow-up

Discharge Summaries

• Reason for discharge• Income sources• Income amounts• Destination• Progress made• Referrals made

Charting Legally Sensitive Situations

• Objectivity• Nonjudgmental

description• Accuracy• Completeness• Legibility• Justify actions taken

Dissatisfied Consumer• Utilize “quotes”• Don’t label - describe• History or crisis

patterns• Attempts to satisfy• Choices provided

made• Never characterize

Noncompliance

• How person refused to comply

• Failure to provide information

• Attempts to remedy• Review of procedures

Confidentiality

• HIPAA• Minimal access - need to know• Privileged communications

Peer Review

• Impartial review• Share expertise• Diversity of opinion• Provide suggestions

Quality Monitoring

• Look at process and outcomes

• Drive improvement• Accountability• Refine service delivery• Track integrity and

effectiveness

Sample Forms

Questions

Coalition on Homelessness and Housing in OhioJonda Clemings, MSEd, LSW175 S. Third St. - Suite 250

Columbus, Ohio 43215Phone 614-280-1984

Fax 614-463-1060www.cohhio.org

jondaclemings@cohhio.org