Documentation -

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Documentation - If it Isnt Written Down - It
Wasnt Done
Jonda Clemings, MSEd, LSW
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Outline for Training

• What should we document?
• Why should we document?
• How should we document?

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What Should We Document?

• Functional limitations abilities
• Barriers that led to homelessness
• Program adherence
• General observation

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Why Should We Document?

• Professional ethics
• Guarding against liability
• Social responsibility
• Consumer benefits
• Requirement

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How Should We Document?

• Precisely
• Objectively
• Avoid documenting outside scope of practice
• Diagnosing

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Documentation Guidelines

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

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Documentation Guidelines

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

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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

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Maintaining a Case FileWhy is it Important?

• Quick access to information
• Enhance service delivery
• Continuity of care
• Record of progress and goal attainment

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Maintaining a Case FileWhy is it Important?

• History of behavioral patterns
• Compliance with regulations
• Records accomplishments

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Building a Case FileWhat Should Be Included
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Identifying Information Picture ID
Ohio State ID

• Drivers license
• State ID
• Birth certificate

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Social Security Cards
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Homeless Status PSH

• On the street
• Emergency shelters
• Transitional housing - coming from streets and
  emergency shelter

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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

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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

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Housing History

• Why moved
• Type of housing
• Difficulties maintaining housing
• Barriers
• Housing needs

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Disability Status

• Long-term, indefinite duration
• Impedes ability to live independently
• Disability could be improved with suitable housing

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Disability Status

• Physical, mental or emotional impairment -
  including impairment solely due to alcohol or
  drug use
• Written documentation must come from credentialed
  professional

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Consent Forms

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

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Educational Vocational Assessment

• Abilities
• Interests
• Personality

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Employment History

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

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Criminal Background

• Criminal history as it impacts housing
  employment

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Psychosocial Assessment

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

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Health Assessment

• Medications
• Medication log
• Allergies
• Illnesses

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Service Plan

• Goals/objectives while in program
• Drives service planning

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SMART Objectives

• Specific
• Measurable/observable
• Attainable within time conditions
• Results-oriented
• Targeted to the identified need impact

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Blooms Taxonomy
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Whose Goal Is It?

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

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Progress Notes

• Refer to service plan
• Describe progress
• Interventions provided

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Income Verification

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

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Incident Reports

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

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Discharge Summaries

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

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Charting Legally Sensitive Situations

• Objectivity
• Nonjudgmental description
• Accuracy
• Completeness
• Legibility
• Justify actions taken

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Dissatisfied Consumer

• Utilize quotes
• Dont label - describe
• History or crisis patterns
• Attempts to satisfy
• Choices provided made
• Never characterize

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Noncompliance

• How person refused to comply
• Failure to provide information
• Attempts to remedy
• Review of procedures

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Confidentiality

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

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Peer Review

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

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Quality Monitoring

• Look at process and outcomes
• Drive improvement
• Accountability
• Refine service delivery
• Track integrity and effectiveness

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Sample Forms
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Questions
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Coalition on Homelessness and Housing in
OhioJonda Clemings, MSEd, LSW175 S. Third St. -
Suite 250Columbus, Ohio 43215Phone
614-280-1984Fax [phone]www.cohhio.orgjonda
clemings_at_cohhio.org