Guidelines for Effective Documentation – Flashcards

What should be contained in a receipt of an expenditure? The purpose of the purchase and the date of the purchase The name of the salesperson with contact information A description of the item, the date of purchase and the amount of expense A supervisor's signature and the balance of the bank account

To maintain organization, what choices should you give yourself for every piece of paper you receive or generate? Shred it, review it, or file it away Recycle it, burn it or give it to a co-worker Put it in your inbox, give it to someone else, or throw it away Throw it away, route it to someone else, act on it now or file it and put it on your master to-do list

When you receive important phone calls or other forms of communication related to the person you support what should you be sure to document? Whether the person you communicated with was correct in what they said Nothing - it is important to put as little as possible in writing The relationship of the person you are communicating with to the person you support The date, time, and method of communication, the person with whom you were communicating, and the content of that communication.

When you document, you will want to consider how the information may be used and... whether there is anything offensive in the content when action will be taken on it how much time you are spending on it who will be reading or using it

What are three things that work together to ensure the person is living a life that reflects their needs and desires? The service plan, your support of the person based on this plan, and the documentation of your support The amount of funding the person receives, the educational background of their staff, and where they live The upbringing of the person, the quality of their education and their character The community the person lives in, the state of their health, and what their needs and desires are

In addition to having knowledge of the service plan what are your responsibilities related to it? To provide and document the services you give to the person as outlined in the plan. To distribute it annually to the individual or their guardian To submit corrections to it on a regular basis To store it in a locked drawer

What are two of the highest priorities in record keeping when providing services to people with disabilities? Billing and passing audits Grammar and punctuation The person's lifestyle preferences, and communication between co-workers Timeliness and wordiness

Your documentation, when reviewed, will help to assure... Adequate income The person is receiving comprehensive services A good job evaluation No citations from the licensing entity

Maintaining accurate documentation while dependably providing excellent services requires what from you? Adequate supervision and oversight Ability to multitask and work quickly A very quiet work environment Good judgment to strike a balance

what does the "contractual" aspect of the annual service plan guide? The community involvement of the person The rules that the service providing agency must follow All services received by the person The number of hours worked by the direct support professional

What are the four rules of incident report writing? Use proper grammar, correct spelling, people-first language and be as subjective as possible Write for an audience, account for everyone and everything, be clear, complete and chronological and consider the attachments Properly diagnose any injuries, give your opinions, use grammatical language and submit the document in a timely manner Write the report in a quiet location, use the proper form, get a statement from the person served and file the report immediately

For documentation to be beneficial it must be... reviewed spell checked approved grammatically correct

What is not appropriate to document in a communication log book? Anything about the person you support Comments critical of others Medical or health information about the person you support Anything is appropriate to document in a communication log book

14. What is one thing you can do to maximize accuracy of what you document when assessing a person? Discuss your observation with others before writing anything down Document immediately after an observation Wait a day or two to get your thoughts together before documenting Get as many impressions from others about your observation before documenting

What should the service plan for the person who is supported reflect? The dreams and goals of the person's parents for the person The strengths and weaknesses of the service provider Their specific strengths and weaknesses of the person who is supported The values, dreams, goals, needs and desires of the person

What are two reasons that documentation is beneficial? Person's behavior will improve and the person will experience fewer outbursts The agency will receive increased revenue and the direct support professional will get a raise More complete communication in emergencies, more accurate assessments, and improved services to the person More 'downtime' for the direct support professional when documenting and less stress

What is one benefit to digitizing documents? To become more computer savvy To reduce paper To improve accuracy To reduce stress

What can your documentation related to a person's health screenings help to ensure? That the doctor receives what he or she needs to diagnose the person correctly That they are receiving the health screenings that are recommended for their sex, age, and medical conditions That the insurance company will not reject the bill That the person is receiving the proper medications

What is one thing you can do while you are working to remember details or events you will document later? Carry a note pad around when working to jot down notes to transcribe later. Tell someone else so they can remind you Repeat it over three times out loud so you will remember Work on memory exercises to build this skill

hat are two things you need to maintain if you assist a person with banking and bill paying? A transaction record and a reconciliation of the transactions An adequate bank balance and a budget Legal guardianship of the person and power of attorney Your documentation as payee for the person you support and the bankbook