Documentation Skills - (2 Hours Training)


Description
The ability to clearly write facts and observations in a person’s record is a critical part of a Direct Support Professional’s responsibilities. While staff in different communities may be using different methods of documentation (e.g. electronic medical records), training must teach staff the basic skills of objective, clear, and concise documentation. The content should be relevant to the specific modes of documentation staff will be using and should meet legal requirements.
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Content
  • OUTCOMES/COMPETENCIES sample
  • Documentation Training
  • Documentation Training
  • Review: Documentation Skills Training
  • Observing, documenting and reporting
  • Observing and Documenting Signs and Symptoms sample
  • Review: Document and Reporting
  • Basic writing skills
  • DISCUSSION TOPIC: Incident Reporting for Sallie Peters
  • Forms for Documentation
  • Care Plans and Support Plans
  • Overview of The Different Types of Forms
  • Sample Form: Medication Record
  • Sample Form: Recipient Rights Complaint
  • Sample Form: AFC Incident/Accident Report
  • Documentation FInal
  • At The Finish LIne!
  • Documentation - Final
  • Survey
  • Documentation - Survey
Completion rules
  • All units must be completed