Documentation - If it Isn t Written Down - It Wasn t Done

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2. Outline for Training What should we document? Why should we document? How should we document?

3. What Should We Document? Functional limitations & abilities Barriers that led to homelessness Program adherence General observation

4. Why Should We Document? Professional ethics Guarding against liability Social responsibility Consumer benefits Requirement Social responsibility Homelessness is an indicator of functional impairment and often a marker of disability. People with disabilities constitute the �chronically homeless� population in America. Disability benefits can help people end and prevent homelessness.Social responsibility Homelessness is an indicator of functional impairment and often a marker of disability. People with disabilities constitute the �chronically homeless� population in America. Disability benefits can help people end and prevent homelessness.

5. How Should We Document? Precisely Objectively Avoid documenting outside scope of practice Diagnosing

6. Documentation Guidelines Follow agency policy Permanent ink Avoid backdating Chronological order

7. Documentation Guidelines No blank space Sign, credentials, date Legible, correct grammar Avoid clich�s

8. Documenting Guidelines Be specific, factual Progress or lack of Document only services you provide

9. On-Going Assessments Assess Review & revise regularly Plan Implement Discuss strengths, weaknesses, and obstacles The participant�s progress toward achieving the goals in the service plan must be documented Service plans should have a column to record outcomes: Provides a quick and easy way to review a participant�s progress. Provides program monitors with performance measurement information without having to read through progress notes Progress notes should provide a more detailed description of events that have occurred and any changes in goals or objectives Goals and objectives should be reviewed and revised on a frequent and regular basis. Allows the participant to see what has been achieved. Provides an opportunity to discuss strengths, weaknesses and obstacles. Provides for the development of new goals. The participant�s progress toward achieving the goals in the service plan must be documented Service plans should have a column to record outcomes: Provides a quick and easy way to review a participant�s progress. Provides program monitors with performance measurement information without having to read through progress notes Progress notes should provide a more detailed description of events that have occurred and any changes in goals or objectives Goals and objectives should be reviewed and revised on a frequent and regular basis. Allows the participant to see what has been achieved. Provides an opportunity to discuss strengths, weaknesses and obstacles. Provides for the development of new goals.

10. Maintaining a Case FileWhy is it Important? Quick access to information Enhance service delivery Continuity of care Record of progress and goal attainment

11. Maintaining a Case FileWhy is it Important? History of behavioral patterns Compliance with regulations Records accomplishments

12. Building a Case FileWhat Should Be Included

13. Identifying Information & Picture ID Drivers license State ID Birth certificate

14. Social Security Cards

15. Homeless Status PSH On the street Emergency shelters Transitional housing - coming from streets and emergency shelter

16. Homeless Status TH Same as PSH - and Evicted within a week - no subsequent resources Discharged within a month - no subsequent resources Fleeing domestic violence - no subsequent resources

17. Chronic Homeless Status Unaccompanied individual Disabling condition Living on streets or emergency shelter 1 continuous year homeless or 4 episodes of homelessness in 3 years

18. Housing History Why moved Type of housing Difficulties maintaining housing Barriers Housing needs

19. Disability Status Long-term, indefinite duration Impedes ability to live independently Disability could be improved with suitable housing

20. Disability Status Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use Written documentation must come from credentialed professional

21. Consent Forms Basic elements of consent Informed choice Overall experience Voluntary participation

22. Educational & Vocational Assessment Abilities Interests Personality Holland�s codes for vocational interests Realistic - outdoors; hands-on occupations Investigative - scientific Artistic - creative Social - counseling and teaching Enterprising - management and sales Conventional - clericalHolland�s codes for vocational interests Realistic - outdoors; hands-on occupations Investigative - scientific Artistic - creative Social - counseling and teaching Enterprising - management and sales Conventional - clerical

23. Employment History Gaps in employment Positions held Frequency of job changes Skills Strengths

24. Criminal Background Criminal history as it impacts housing & employment

25. Psychosocial Assessment Mood & affect Cognitive functioning Memory Communication Appearance Mobility

26. Health Assessment Medications Medication log Allergies Illnesses

27. Service Plan Goals/objectives while in program Drives service planning

28. SMART Objectives Specific Measurable/observable Attainable within time & conditions Results-oriented Targeted to the identified need & impact Why have objectives? Creating clear objectives during the service planning process serves the following purposes: Helps consumer and staff integrate all aspects of the plan Serves to connect implementation and evaluation to define impact Provides a clear focus for development and implementation Forms the basis for evaluating outcomes and successes Why have objectives? Creating clear objectives during the service planning process serves the following purposes: Helps consumer and staff integrate all aspects of the plan Serves to connect implementation and evaluation to define impact Provides a clear focus for development and implementation Forms the basis for evaluating outcomes and successes

29. Bloom�s Taxonomy

30. Whose Goal Is It? Participant agreement & responsibility Central issue & priorities CM - supporting role In order to create an effective service plan, there has to be an agreement about the work to be done. The participant and case manager may be different ideas about what the central issue is and what are the priorities. The participant must feel that they are working towards getting what they want. Case managers should be aware of their own agenda and be willing to give up the idea that we can control someone else�s life. On the flip side of that, participants must be willing to take responsibility for their own lives. In order to create an effective service plan, there has to be an agreement about the work to be done. The participant and case manager may be different ideas about what the central issue is and what are the priorities. The participant must feel that they are working towards getting what they want. Case managers should be aware of their own agenda and be willing to give up the idea that we can control someone else�s life. On the flip side of that, participants must be willing to take responsibility for their own lives.

31. Progress Notes Refer to service plan Describe progress Interventions provided

32. Income Verification Amount of income Sources of income Proof of income

33. Incident Reports What happened When it happened Others involved Follow-up

34. Discharge Summaries Reason for discharge Income sources Income amounts Destination Progress made Referrals made

35. Charting Legally Sensitive Situations Objectivity Nonjudgmental description Accuracy Completeness Legibility Justify actions taken

36. Dissatisfied Consumer Utilize �quotes� Don�t label - describe History or crisis patterns Attempts to satisfy Choices provided made Never characterize Be specific. Effective charting is factual. Use words that reference participant reaction, attitude, and symptoms. Mention specific progress or lack of progress. Don�t label a participant�s behavior without describing it. For example: harry Homeless was anxious as evidenced by pacing, hand writing, and fast paced speech. Never characterize the participant�s behavior with unflattering and unprofessional adjectives such as spaced out, flipped out, drunk as a skunk, etc. Don�t use the words appears or seems to without adding a statement such as as evidenced by or as indicated by Do use participant quotes, or paraphrase what he/she says � remember to utilize quotation marks if using quotes Be specific. Effective charting is factual. Use words that reference participant reaction, attitude, and symptoms. Mention specific progress or lack of progress. Don�t label a participant�s behavior without describing it. For example: harry Homeless was anxious as evidenced by pacing, hand writing, and fast paced speech. Never characterize the participant�s behavior with unflattering and unprofessional adjectives such as spaced out, flipped out, drunk as a skunk, etc. Don�t use the words appears or seems to without adding a statement such as as evidenced by or as indicated by Do use participant quotes, or paraphrase what he/she says � remember to utilize quotation marks if using quotes

37. Noncompliance How person refused to comply Failure to provide information Attempts to remedy Review of procedures

38. Confidentiality HIPAA Minimal access - need to know Privileged communications

39. Peer Review Impartial review Share expertise Diversity of opinion Provide suggestions

40. Quality Monitoring Look at process and outcomes Drive improvement Accountability Refine service delivery Track integrity and effectiveness

41. Sample Forms

42. Questions

43. Coalition on Homelessness and Housing in OhioJonda Clemings, MSEd, LSW175 S. Third St. - Suite 250Columbus, Ohio 43215Phone 614-280-1984Fax 614-463-1060www.cohhio.orgjondaclemings@cohhio.org