Initial and Annually

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.
Content
  • OUTCOMES/COMPETENCIES sample
  • DOCUMENTATION
  • Documentation Training
  • Basic writing skills
  • Observing and Documenting Signs and Symptoms
  • Documenting and Reporting Facts
  • Document and Reporting Quiz
  • Care Plans and Support Plans
  • Sample Forms
  • FORMS
  • Various Documentation Forms
  • Sample: Medication Record Form
  • Sample: Health Care Chronological
  • Sample: Recipient Rights Complaint Form
  • Sample: AFC Incident/Accident Report Form
  • MCCMH - Use of Physical Management Form
  • MCCMH - Emergency Medical Form
  • writing PRACTICE SCENARIO
  • DISCUSSION TOPIC: Sallie Peters
  • REVIEW YOUR WORK!
  • At The Finish LIne!
  • Survey
  • Documentation - Survey
Completion rules
  • All units must be completed