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Ensuring the accurate completion of AFC Incident Reports is vital. These reports play a pivotal role in resident safety, legal compliance, quality enhancement, and fostering accountability. They serve as essential documentation for communication, preventing recurrence of incidents, and promoting transparency. By adhering to rigorous reporting standards, we prioritize resident well-being, demonstrate professionalism, and maintain the highest standards of care within our AFC homes.
Effective documentation is a cornerstone of healthcare, enabling healthcare professionals to provide quality care, maintain legal compliance, and protect themselves and their organizations. Open Arms Link follows specific guidelines and standards for documentation, emphasizing the importance of accuracy, completeness, confidentiality, and professionalism. Adhering to these guidelines ensures that healthcare providers deliver the best care possible while maintaining legal and regulatory compliance. In healthcare, if it wasn't documented, it didn't happen.
The value of documentation lies in its ability to facilitate effective planning of activities and treatment programs, ultimately enabling healthcare providers to deliver the best care possible. It also serves as a legal safeguard, protecting healthcare professionals and organizations from potential legal consequences.
To ensure effective documentation, Direct Support Professionals must adhere to key principles:
completeness
accuracy
objectivity
timeliness
confidentiality.
By following these principles, healthcare professionals can create detailed and reliable records that paint a clear picture of a patient's condition and treatment.
Types of Documtation
DSP professionals need to maintain various types of documentation, including individual clinical records, residential records, Personal Care and Community Living Support Logs, medical records, progress notes, incident reports, and other company/house logs. These documents serve to ensure individual care, regulatory compliance, and accurate record-keeping in healthcare settings.
Open Arms Link, a forward-thinking organization, has made the strategic decision to transition from traditional paper-based documentation to digital documentation systems. This transition reflects the organization's commitment to enhancing efficiency, improving individual care, and staying aligned with industry advancements.
Residential Records
The Residential Record contains information that applies specifically to the residential setting. DSPs who provide residential services can use the Residential Record to get information to better assist the person they are serving. Information contained in the Residential Record includes (but is not limited to);
Incident Reports
Progress notes
Medical Records
Home Specific Treatment Plans
Health Care Information
Medical Records
Medical records are essential in healthcare for several reasons:
They provide a comprehensive health history of patients, aiding in treatment decisions.
They enable care coordination among healthcare providers.
They are crucial for managing chronic health conditions over time.
They help prevent medication errors by maintaining medication records.
They serve as references for direct care staff, ensuring proper care for the individual.
Day Program Records
The Day Program Record contains information that applies specifically to the Day Program setting.
Staff who provide Day Program services can use the Day Program Record to get information to better assist the person they are serving.
Information contained in the Day Program Record includes:
Incident Reports
Progress notes
Medical Records
Program Specific Treatment Plans
Health Care Information
Day Program Records Information contained in the Residential & Day Program Records can often overlap. All documentation from the Residential and Day Program Records are merged into the Individual’s Clinical Record.
House Logs aka "ECP Recent Notes" (Shift Summaries)
The ECP Recent Notes or "Shift Summaries", which may also be referred to as The House Log, Staff Log, Communicator, or End of Shift Summary, serves as a vital communication tool for staff to exchange important updates about each individual at the end of their shift. This informal method of communication encompasses several key elements;
It includes documenting the activities in which the individuals engaged throughout the shift
provides an overview of the kind of day the consumer had,
notes any specific items that incoming staff may need to follow up on for each individual
highlights any concerns that the staff should be aware of to meet the individuals' needs during the upcoming shift.
Since the ECP Recent Notes/Shift Summaries (or one of its alternative names), follows an informal structure, it is essential for staff to maintain professionalism when recording information, using the Individuals' initials, good documentation skills to ensure that the records are clear, accurate, and comprehensive. This ensures that the Shift Summary (known by different names), remains an effective means of sharing critical information among the staff. The ECP Recent Notes/Shift Summary is NOT used as to make complaints or address staff concerns. Any concerns should be directed to the DSP's direct supervisor.
**The Shift Summary should be read at the start of your shift. Employees should be reading all Shift Summaries from the last time they were scheduled, to ensure that no important information is missed. The DSP will acknowledge they have read each summary by clicking the envelope icon ✉️ to the left of entry. (Topic covered in EHR/eMAR Training) **
Progress Notes (Daily Task)
Progress notes are a crucial documentation task for direct service providers. They have two main functions:
Documenting service delivery.
Tracking the progress of treatment.
These notes are based on the treatment plan, recording planned activities and their details. The progress of treatment is summarized by describing goals, outcomes, next steps, and scheduling future activities. These notes are essential for maintaining evidence-based practices in healthcare.
Open Arms Link uses a Electronic Health Record and Electronic Medication Administration Record or EHR/eMAR system called, Extended Care Professionals or "ECP" as you will hear it commonly referred. With this system, Open Arms Link can ensure that DSPs are accurately charting all required documentation.
*Every DSP working in the homes will complete in-home documentation training on the EHR/eMAR system with an Operational Manager, Home Manager, or a trained direct support professional. Once in-home training is completed, DSPs will be scheduled 1 on 1 training with an Open Arms Link EHR/eMAR Systems Admins. THIS TRAINING IS MANDATORY
Always use acronyms that have been approved by CMHA-CEI.
A list of approved acronyms can be located on page 4 of Procedure # 3.2.13A, “Clinical Service Documentation – Physical File”
This procedure can be found on the CMHA-CEI Intranet by clicking on the following path:
Reference Material
Policies, Procedures, Guidelines, Forms
Procedures
Clinical Procedures
Documentation Skills
Your documentation skills can have a major effect on the quality of services received by an individual. It's essential to keep the reader in mind when writing, as this person is probably not familiar with the individual you are documenting. Always communicate in a manner that the reader will understand.
Here are some basic skills that will increase the effectiveness of your documentation:
Be Timely
Complete the report as soon as possible. This will produce a more accurate and detailed report. According to the Incident Report Procedure, an incident report must be completed by the end of the workday. Be prompt in your documentation.
** No employee is allowed to leave work until all their documentation is completed for the day! **
Be Objective
Only document what you personally observed. Do not document for another staff and sign their name. Avoid documenting based on "Hear Say" from another staff. Use quotes whenever possible.
Be Accurate
Avoid using general, vague, or subjective terms. Use specific, objective, and complete statements in your documentation. "Paint" a complete picture for the person reading your documentation.
Be Specific and Non-Judgmental
Describe your observations in a non-judgmental manner and avoid personal opinions. For example, right documentation might say, "Susan did not make her bed this morning. Her dirty clothes were left on the floor," while wrong documentation would make a subjective judgment like, "Susan is a slob."
Use Measurements
Avoid words like "a lot," "a few," "a little bit," etc. Instead, use amounts that can be measured. For example:
Jane cried for 15 minutes after getting her TB shot.
Karla ate 12 brownies after dinner.
Marcia watched TV for 5 hours.
Maintain Confidentiality
Avoid using one consumer's name in another's report. If you must reference another consumer, refer to them by case number, initials, or similar means. Do not leave physical documents where they are accessible by consumers or unauthorized personnel.
Confidentiality and Access Control
Only those staff members involved in the care and treatment of the consumer and staff with a bona fide need to know the information shall be allowed access to the clinical record.
All clinical documents will be prepared using the consumer's case number on each page.
The clinical record is the property of the facility and shall not leave the premises, except as permitted by a defined agency procedure.
By following these guidelines, you can improve the quality of your documentation and ensure it effectively conveys important information about individuals receiving services.
Words To Use Consider When Documenting
When documenting in daily notes, the DSP be should use words like;
Prompted
Assisted
verbally redirected
monitored
facilitated
observed
supported
Words or sayings the DSP SHOULD AVOID
"I told him no."
"He can't do that"
"I told him to go to his room"
"I think that (insert opinion)" *Keep your opinion out of your documentation*
Examples of Good/Bad Documentation
Bad Documentation Example:
"On Tuesday, I dealt with the usual mess caused by Val. She's always such a slob. The living room was a disaster, and it took forever to clean up after her. She never listens to instructions and is impossible to deal with."
In this example, the documentation is problematic for several reasons:
It uses derogatory language ("slob") and makes a negative judgment about the individual (Val).
The description is vague and lacks specific details about what actually happened or what instructions were given.
It lacks professionalism and objectivity, focusing on personal frustrations rather than factual information.
Bad documentation can be counterproductive and may lead to misunderstandings or disputes. It's crucial to maintain a respectful and objective tone in documentation to ensure that information is clear, accurate, and useful for care and decision-making.
Good Documentation Example:
"On Tuesday, I observed that the living room was in disarray. There were scattered books, toys, and dishes on the floor. I provided verbal prompts to Val to clean up the living room, and she began picking up her belongings. After approximately 20 minutes, the living room was neat and organized. Val completed the task with my assistance."
In this example of good documentation:
The language used is objective and non-judgmental, focusing on the facts rather than personal opinions about the individual (Val).
Specific details about the situation are provided, such as the condition of the living room and the actions taken by the DSP.
The documentation is professional and maintains a respectful tone.
Good documentation is crucial for accurately conveying information, tracking progress, and ensuring that individuals' needs are met effectively. It serves as a valuable tool for caregivers, supervisors, and healthcare professionals.
Guidelines for Handwritten Documentation
The "Do's"
Describe events in the order they occurred.
Sign first, last name and job title
Use person’s legal name or case #
Draw a line through unused space between the end of your comments and your signature.
Write in permanent black Ink
Write legibly so other can read your writing.
The "Don'ts"
Erase, scribble, blot, or white out errors.
Postpone
Change any record for any reason.
Use one person’s full name in another person’s record.
Erasable inks, felt-tip pens or pencil are not permitted.
Adhering to basic do's and don'ts in documentation is essential. DSPs should focus on describing events chronologically, signing with their first and last name and job title, using the individual's legal name or case number, and writing legibly in permanent black ink. DSPs should avoid erasing, scribbling, blotting, or white out errors, postponing documentation, changing records, using one person's full name in another person's record, and using erasable inks, felt-tip pens, or pencil.
No portion of the original document is to be obliterated, erased, altered, or destroyed.
The only individual who may change an incorrect entry in the record is the individual who originally entered the incorrect information.
Falsification of information or tampering with a record is a criminal offense, which is subject to progressive discipline up to and including immediate termination from employment or other legal consequences.
Correcting Errors in Handwriting Documentation
Draw one line through the error. The incorrect information must still be legible.
Do not obliterate the error with white-out, or scribble over the writing.
Designate the entry as an error.
Initial and date the error.
Incident Reports (IR's)
Reporting incidents correctly and promptly is crucial in addressing any issues that may arise. CMHA-CEI provides clear guidelines on what constitutes an incident and when to file an incident report.
What is an incident?
an occurrence that disrupts or adversely affects the course of treatment or care of a consumer.
Who should fill out an Incident Report (IR)?
An Incident Report needs to be completed when staff either witness or are the first to become aware/informed of an incident involving a CMHA-CEI consumer who is actively receiving services.
For the sake of reporting, a consumer is considered to be actively receiving services when any of the following occur:
A face-to-face intake has occurred and the individual was deemed to be eligible for on-going service, or
CEI has authorized the individual for ongoing service, either through a face-to-face assessment or a telephone screening, or
The individual is currently receiving a screening service in Crisis Services.
The individual has received a non-crisis, non-screening encounter.
Some Examples of incidents that need to be reported to CMH-CEI:
Arrest
Behavioral Event
an event by a consumer that results in serious aggression towards others, serious property damage or serious self-injury.
Choking
Death
Emergency Care
For injury or illness which requires an intervention beyond first aid (urgent care, emergency room visit, or hospitalization.)
Exposure to Blood / Body Fluids
Medication Error/Event:
Any occurrence involving a medication that places a consumer at risk due to a variance in medication processes.
You will receive more detailed information in the Basic Health & Medications Class
Missing Recipient
Physical Intervention
Search and Seizure
Search of the person, the person's property or their living space and the removal of said person’s belongings.
Sentinel Event:
An unexpected occurrence to a recipient of services involving death or serious physical or psychological injury, or the risk thereof.
**Please note that AFC administrative rules R400.14311 Investigation and Reporting of Incidents, Accidents, Illness, Absence, and Death requires Incident Reports for the following:
(1) If a resident has a representative identified in writing on the resident’s care agreement, a licensee shall report to the resident's representative within 48 hours after any of the following:
(a) Unexpected or unnatural death of a resident.
(b) Unexpected and preventable inpatient hospital admission.
(c) Physical hostility or self-inflicted harm or harm to others resulting in injury that requires outside medical attention or law enforcement involvement.
(d) Natural disaster or fire that results in evacuation of residents or discontinuation of services greater than 24 hours.
(e) Elopement from the home if the resident’s whereabouts is unknown.
(2) If an elopement occurs, staff shall conduct an immediate search to locate the resident. If the resident is not located within 30 minutes after the elopement occurred, staff shall contact law enforcement.
(3) An incident must be recorded on a department-approved form and kept in the home for a period of not less than 2 years.
(4) The department may review incident reports during a renewal inspection or special investigation. This does not prohibit the department from requesting an incident report if determined necessary by the department. If the department does request an incident report, the licensee shall provide the report in electronic form within 24 hours after the request. The department shall maintain and protect these documents in accordance with state and federal laws, including privacy laws.
"If in doubt, fill it out!"
Chances are likely, if you THINK and Incident Report needs completed, then an Incident Report needs to be completed
In conclusion, effective documentation is vital in healthcare, and following specific guidelines and standards is crucial for providing quality care, maintaining legal compliance, and protecting healthcare professionals and organizations. By ensuring accurate, complete, and confidential documentation, healthcare providers can deliver the best care possible while upholding legal and regulatory standards. Ultimately, in healthcare, if it wasn't documented, it didn't happen.
Now that you have completed the Documentation module, please proceed to take the test. To successfully complete the course, you must achieve a passing score of 80% or higher.
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