5060-D Professional Documentation

Georgia State Seal

Georgia Division of Aging Services
Access to Services Manual

Chapter:

5000 Aging and Disability Resource Connection (ADRC)

Effective Date:

Section Title:

Professional Documentation

Reviewed or Updated in:

MT 2015-04

Section Number:

5060 Appendix D

Previous Update:

ADRC Documentation Module

Purpose of Module:

  1. Explain how documentation helps staff with supporting informed decision making of individuals.

  2. Provide guidance regarding what to document; and

  3. Provide guidance regarding how to document.

Purpose of Documentation:

  1. Documentation is the ‘glue’ that holds together all of the steps involving your work as counselors.

  2. Documentation is very important.

  3. Each case note in the DAS Data System is the narrative describing the background/ history:

    • Presence of a Legal Guardian

    • Past involvement of Adult Protective Services (APS)

    • Needs, preference and values of the individual

    • Cultural awareness

    • All options discussed with individual to include public and private pay resources

    • Development of an action plan working to empower the individual to move forward with their desired goal.

    • Referrals made to appropriate programs on behalf of individual

    • Communication with NH staff, other family members and community partners as agreed to by individual

    • OC specific: Follow-up contacts at 14, 90 and 180 days. Answer questions, revise action plan as needed, make any necessary referrals, research and provide additional information to the individual

    • Need to involve the Long Term Care Ombudsman (LTCO)

    • It is a working instrument to record the individual process

    • It will serve as a record of what the OC has completed and what needs to be completed.

    • It is a formal record of the agency’s work. As such, it is the documentation to your supervisor, DAS Options Counseling Specialist, Individuals, and, potentially the courts that the Options Counseling Program has done an adequate job of its work.

    • It is a formal record for funding sources that the ADRCs as the Local Contact Agencies and the MDSQ Options Counseling Program OCs are handling MDS Section Q referrals and meeting set obligations

    • Documentation helps

State facts in a clear format:

  • Documenting your interactions and observations forces you to be clear and factual about the situation. Your impressions, emotions, and preconceived ideas are removed from capturing the facts. Also, when handling referrals for multiple individuals residing at multiple nursing homes, the documentation will remind you of important details on each referral.

  • Clear documentation enables someone else to pick up, if necessary, where you left off. This is extremely important with moving a referral forward without losing valuable time or increasing an individual’s stress level.

  • Being able to read ‘just the facts’ can help to organize thoughts around supporting an individual with their decisions.

Organize thoughts:

  • Throughout the steps in the options counseling process, OCs need to stop and analyze what they know, what else they need to understand and to strategically plan with the individual the next steps. Having key elements in writing enhances your ability to effectively move through the options counseling process with the individual.

Track Progress:

  • You can review documentation to see the status of the work being conducted with the individual, time frames for OCs actions, time frames for other facility’s actions and to determine what else needs to be done.

  • Identify barriers to transitioning to the community

  • Over time, documentation provides a picture of barriers for individuals to transition to the community by identifying patterns.

  • Documentation demonstrates options counseling impact on individuals transitioning to the community and on relationships/ partnerships with nursing facilities.

  • Review of documentation from across the state may reveal the need for a change in policy or regulation to correct widespread problems preventing transitions.

Provide a ‘safety net’:

  • Documentation is more reliable than memory of events and actions in responding to MDSQ and non-MDSQ referrals. Sometimes it reassures an individual that you took their concerns seriously and did everything possible to assist the individual with meeting their goals related to returning to the community to live.

  • Documentation is sources of specific information of questions arise later on down the road as to how a referral was handled. It is the indicator of the quality of OCs work and compliance with standards and procedures. If necessary, it can assist the DAS Options Counseling Specialist in supporting OC actions as well as maintaining credibility of a statewide program.

Establish credibility:

  • Maintaining good documentation adds credibility to decisions that are reached. It will demonstrate referral sources, active listening and discovery, assistance to individual with informed decision making process, referrals to other agencies, creation of action plans and meeting requires follow-up contacts.

  • Clear statements of the person’s needs, preferences and values

  • Individual’s involvement in their transition to the community

  • Individual’s permission to receive options counseling

How to Document: Fact versus Opinion

  • Use objective language in your documentation. It is a natural tendency to want to add personal opinions and perceptions with the facts. As an Options Counselor, your documentation must be factual and objective.

  • Avoiding recording subjective information in the history notes unless you substantiate this with facts and/or record it as a direct quote from an individual and identify who the individual is related to the quote.

    • FACTS - are client activities, agency actions and/or information from official records or documents. In addition, facts may be straightforward descriptions of circumstances.

    • Example - Ms Smith stated she would need assistance with a utility deposit in order to transition out of the nursing home.

    • Examples - Ms Smith stated it is important to her to return to her family home to care for her pet cat.

    • OBSERVATIONS - are recorded notes about the client, condition of a home, physical injury and/or seen by the Options Counselor. When recording observations, the source of the information must be clear.

    • Example - The Options Counselor observed Ms Smith crying and clenching her fists.

Notes should include:

  • Date-When documenting dates, enter the month, day and year, not ‘by next week’

  • Options Counselor’s name

  • Type of Activity (face to face, telephone call, email, fax, etc.)

  • Who was contacted

  • Purpose of contact

  • Significant information or observations

The narrative should be written in such a manner that any person will understand exactly what transpired during the case, from beginning (when the referral was received) to end (180 day follow-up) whether they were involved or not.

The narrative ‘paints a picture’ for the reader to see. It begins with the MDSQ or non-MDSQ referral as received by the ADRC and documented in the DAS Data System.

Judgment terms should not be used in history notes. If used, they must be clarified with clear descriptions.

  • I.e. - Instead of recording “Ms. Smith will obtain adequate housing”, state- “Ms Smith will obtain adequate housing that at a minimum has running water, electricity, one bedroom, bathroom and kitchen.”

  • I.e. - instead of stating, “Ms Smith’s family is dysfunctional”, state “I observed Ms Smith, her husband and her daughter screaming at one another during the face to face meeting.”

Avoid words/phrases such as ‘appeared’, ‘seems to be’; ‘apparently’, which may indicate the observation is uncertain. Labels such as ‘alcoholic’, ‘schizophrenic’, ‘incompetent’, ‘incapacitated’, and ‘mentally retarded’ shall not be used in isolation and will ONLY be used when a certified or licensed professional has made such a diagnosis or when quoting someone.

  • I.e. - Instead of saying, “Ms Smith is an alcoholic,” it is better to state, “Options counselor observed Ms Smith to have slurred speech, staggered walk and her breath smelled of alcohol.”

  • I.e. - Ms Smith’s daughter said, “It is embarrassing to have an alcoholic for a mother.”

Differences in objective and subjective examples:

Use Objective Language Avoid Subjective Language

Can be measured, counted, and seen by more than one person. Two people would have the same understanding of the situation.

Is open to different interpretations. Two people can describe or understand the meaning in different ways.

Word examples: Hit, run, cried, slept, does not speak, laughs, talks to other people

Word examples: depressed, dumb, confused, unable to relate, violent temper, stubborn, lack of respect, an alcoholic, inconsiderate, typical, filthy, friendly

Describe behaviors: I.e. - “Client stated he had no comment when I asked him about wanting to move home with his adult child. After I asked more questions about wanting to return to the community the client asked me to leave his room and not bother him.”

Labels Behavior: I.e. - “Client was rude and unresponsive during my interview.”

Describe observations: I.e. - “I saw the client struggle to pull herself to a sitting position for the meeting.”

Interjects opinion/offers as interpretation: I.e. - “The client could not sit up and obviously needs 24/7 care.”

In the DAS Data System, it is best to indicate and acknowledge an error with phrasing such as “CORRECTION to entry dated 00/00/0000 and proceed to document the correction.

Don’t document “He/She refused services.” Do document, “He/She said “Leave me alone.” Document editorial comments - “He/She never returns my phone calls/emails.” Instead document specific dates/times calls/emails placed to a specific person or agency.

Subjective, Vague and Judgmental Terms

The following list gives examples of subjective, vague and judgmental terms. (It is not an all-inclusive list) Subjective, vague and judgmental terms are not to be used in isolation. If used, clarify by using descriptive works. Judgmental terms are used ONLY when quoting someone.

Subjective, Vague Terms

Abusive

Messy

Adequate

Neat

Angry

Neglectful

Apparently

Nervous

Appeared

Nurturing

Appropriate

Obviously

As soon as possible

Offensive

Clean/dirty

Physical

Cluttered

Proper

Good/poor housekeeping

Quality

Happy/sad

Regular

Healthy

Seems to be

Hostile

Suitable

Hyper

Stable

Hysterical

Unmotivated

Immediately

Upset

Loud

Verbal/non-verbal

Incompetent

Tidy

Incapable

Well cared for
Judgemental Terms

Dysfunctional

Filthy

Junky

Lazy/sorry

Nasty

Obnoxious

Druggie

Unfit

Slob

5 “W”s and a “H”: Information Gathering and Reporting

Who

  • Is the primary reader?

  • Else will read this case note?

  • Are you to the reader?

  • Should perform these actions?

What

  • Do you hope to accomplish?

  • Criteria are you using?

  • Is fact, what is opinion?

  • Is the solution?

  • Are the alternatives?

  • Questions might the reader ask?

  • Does the reader already know about the subject?

Why

  • Are you writing?

  • Are you writing now?

Where

  • Does the communication lead?

  • Are the reader’s biases?

  • Is the reader’s resistance?

  • Did event/actions occur?

When

  • Will additional information be available?

  • Will actions/events/resolutions occur?

  • Are deadlines? (i.e. eligibility requirements, face to face visits, follow-up contacts, etc.)

How

  • Did this happen?

  • Have the conclusions been reached?

  • Will this be handled?

  • Will this be avoided in the future?

Case Notes: At a minimum the formal case note must include the type of contact, staff person who made the contact, time spent on the contact (time spent box) and detailed information as to the items discussed and concerns presented, any given information and unmet needs in a factual manner. Formal case notes need to be written in such a way to avoid the use of personal opinion, judgment calls and biases toward the individual transitions.