3060 Documentation Standards | PUBLIC-GUARDIANSHIP-5800-MANUAL

Professionalism is reflected in the style in which the documentation is written. PGO documentation must be formal and well-written. For PGO documentation standards, “formal and well-written” means:

Documentation that is a straightforward, concise recitation of circumstances or events is also permitted.

Descriptive information is the “who, what, when, and where” details. Explanatory information is the “how and why” details. Description gives the note reader a mental picture of what the author experienced, but the reader also needs explanations to understand the significance or relevance of what the author experienced.

PGO documentation must be factually correct. PGO staff must ensure that all documented information is factually correct, but staff must use special care to guarantee the correctness of:

Other aspects of accuracy are:

Timely documentation is documentation that meets all standards of promptness as spelled out by is this chapter.

All case management activities shall be entered into the DAS database system (DDS) case notes and marked complete no later than five business days after the activity.

PGO staff shall:

When attaching documents, images, or other electronic files into the case record, PGO staff shall:

PGO staff must enter a separate note for each discrete case management action.

PGO staff must enter a case note on all case management activity they perform, even if not the primary worker assigned to the case. For example, if a supervisor receives an emergency call on the weekend about a case or a lead worker makes a client visit for a case manager who is on sick leave, the supervisor and lead worker must enter notes about the call or the visit.

After documentation has been entered and saved as complete in the case record, it shall not be deleted or altered. Documentation with errors, such as incorrect dates, misspelled words, grammar errors, etc., shall not be deleted; however, material errors must be corrected. A material error is one that is factually incorrect or changes the meaning of the documentation. Minor errors do not require corrections. Examples of minor errors are misspelled words still recognizable as the intended word or grammar errors that do not change the meaning of the documentation.

Corrections shall be made by entering a new note that states that it is a correction to a previous entry and that references the date and description of the incorrect note.

Examples:

Exception: entering client information into the wrong record. PGO staff must notify the supervisor of this type of error, and the supervisor shall then notify PGO management. Only PGO management may request removal of the note from the case record.

PGO staff are required to complete assessments contained in the DDS on all persons under DHS guardianship.

The Initial Client Assessment must be started within 10 calendar days after initial contact with the person under guardianship and completed no later than 30 calendar days after assignment. Update when needed.

The Determination of Need-Revised (DON-R) must be started within 10 calendar days after initial contact with the person under guardianship and completed no later than 30 calendar days of assignment.

The Case Plan is due and should be documented DDS within 30 calendar days of case assignment for permanent guardianships. For temporary guardianships, the due date will be determined by the length of the guardianship as stated in the court order. The annual case plan is due within 30 calendar days of the anniversary of the guardianship appointment.

A Critical Incident Report (CIR) must be made in DDS no later than five business days of the date of the incident. The CM’s supervisor must be notified immediately of the death of a person under guardianship and within 24 hours of the occurrence of all other critical incidents. As appropriate, regulatory bodies must be notified in accordance with Section 4006.

In addition to documents identified in other sections of MAN5800, PGO Staff are required to obtain and upload into DDS a client’s:

As well as copies of the:

A Death Certificate or Pronouncement of Death shall be uploaded into DDS by the Section Manager at case closure for deceased clients.

PGO Staff are required to complete other documents not contained in the DDS system but related to legal and reporting requirements, as well as the care and, well-being of the person under guardianship.

The initial PSR must be submitted to the probate court within 60 calendar days after the appointment of guardianship and then annually within 60 days after each anniversary date.

When a client has a successor guardian appointed, has his or her rights restored, or dies, a final PSR must be completed and submitted before the case is closed.

The Client Notification letter must be mailed to the client and copy uploaded in DDS no later than five business days after receiving a new case assignment.

Purdue Online Writing Lab:

Joe Schall, Pennsylvania State University e-Education Institute, Effective Technical Writing in the Information Age, available at www.e-education.psu.edu/styleforstudents/node/1787

U.S. Food & Drug Administration, Drug Information for Consumers, available at www.fda.gov/drugs/resources-you/drug-information-consumers

National Institutes of Health, National Library of Medicine, MedlinePlus, Trusted Health Information for You, available at medlineplus.gov/

Florida Developmental Disabilities Council, Inc., Lighting the Way to Guardianship and Other Decision-Making Alternatives, based on Florida law but sections on the concepts of person-centeredness and self-determination in guardianship are applicable, available at www.fddc.org/sites/default/files/LTW_FamilyManual2017%20-%201.pdf