Embed Size (px)
Citation preview
Case Records &
DocumentationStandard 27
IFSTAN WebinarTuesday November 15, 2016
10:00 am
Standard 27
The organization maintains a case record for each family that contains
sufficient, accurate information to: identify the consumer; support
decisions about interventions or services; and
document the delivery of services.
Interpretation: In addition to supporting the delivery of services, case records are an important risk
management tool. Well-maintained records can help shield the organization from allegations of
misconduct and negligence, while poorly-maintained records and improper documentation are known as
a liability.
Let’s break that down…
Case records are an important risk management tool.
If it’s not documented, it didn’t happen! If it happened document it thoroughly
and as soon as possible to maintain integrity.
Well-maintained records can help shield the
organization from allegations of misconduct and
negligence.
Well maintained records leave no doubt or room
for interpretation or misinterpretation during file audits
or during Peer Review.
Poorly-maintained records and improper documentation are known
as a liability.
Documents missing information or inadequately filled out can be subjective
and/or cause inadequacies in service delivery, be cause
for ill preparedness of file audits, or legal issues should the agency/program be
challenged.
27.01
Case records comply with all legal requirements and contain information
necessary to provide services, including:
� demographic and contact information;
� the reason for requesting or being referred for services;
� up-to-date assessments;
� the service plan, including mutually developed goals and objectives;
� copies of all signed consent forms;
� a description of services provided directly or by referral;
� routine documentation of ongoing services;
� documentation of routine supervisory review;
� discharge or aftercare plan;
� recommendations for ongoing and/or future service needs and assignment of
aftercare or follow-up responsibility, if needed; and
� a closing summary entered within 30 days of termination of service.
Wait, what?!Forms that your programs use should be filled
out completely. Required information should be gathered at intake, collected throughout service
delivery, updated as needed, and maintained for
the duration of services.
Do not leave blank spaces. If information is
unknown or unable to be obtained, note it so that documents are as complete as possible.
27.01 Interpretation: Describe the basic elements to be included in individual case records. We
recognize that in some cases not all listed information is obtainable for a person or family. In
these cases, an explanation should be placed in the case record.
27.02
Case record entries are made by authorized personnel only, and are:
� specific,
� factual, � relevant,
� and legible;
kept up to date from intake through case closing; andcompleted, signed, and dated by the person who provided the service.
There is no “interpretation” for 27.02. therefore it is of the utmost importance
to ensure that case records are meticulously cared for from intake through case closing and into aftercare.
Documentation During Peer Review
During your peer review the reviewers utilize checklists in
order to seek out required elements of documentation that meet the Iowa Family Support Standards.
Particularly in documentation, reviewers are looking for
documents to be filled out completely, dates information is
documented, and that items such as assessments are completed at intervals that match your program’s policy.
Sample Checklist
Note on the checklist that other standards appear. Documentation
requirements can be met via many avenues throughout program practices and the Iowa Family Support Standards.
Documentation can be found via;
� Intake Practices � Screening Practices
� Assessments
� Service Plans
� Family Involvement � How Needs Are Met
� Services & Education
� Progress Toward Self-sufficiency
� Referrals
� Case Notes
To name just a few… let’s take a closer look!
A Closer Look
Although Case Records live within Standard 27 there are inclusive documentation
pieces throughout the Iowa Family Support Standards. These additional pieces will help your program complete documents and meet the requirements for Peer Review.
2.01 *6.03 10.02 20.02
*3.02 8.01 10.03 21.01
*3.03 8.02 10.04 21.04
*3.04 8.03 *11.01 27.01
*3.05 8.04 *11.03 27.02
*4.01 9.01 *11.04 32.03
*4.02 9.02 *13.01
*6.01 9.03 14.07
*6.02 9.04 20.01
*Some of these standards will be NA for Group Based Programs and Short Term Home Based Programs.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standard 2.01
This is where you’ll start to see the
importance of keeping dates trackedand aligned with services. This will
impact your peer review.
Good documentation will show how
your program addresses each of thesepoints. Utilize your intake forms,
screening tools, and any document the
family signs.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 3.02, 3.03, 3.04, 3.05
Specific and Factual
Meet the participant where they are
and document how it is done. Define
and document resources used as well
as the results.
Assessments are always dated upon
completion. Intervals should align with
your program’s policy.
Ensure these documents are complete,
up to date, and regularly maintained.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 4.01, 4.02
Pay attention to details that lead
service plans; dates, participant’s
goals/needs… document who is present
and who participates in the process.
Document the participant’s thoughts,
quote their words, show how they lead
the process.
Highlight areas where participant’s
strengths are utilized, point out potential
barriers and how to overcome them.
SIGNATURES & DATES!!
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 6.01, 6.02, 6.03Document participant’s reactions to
services, referrals, visits, interactions.
Discuss and document participant’s preferences
to availability. Discuss and document participant’s
preferences regarding who is present during visits.
Records will show a leveling or frequency
system or the participant’s requested service
involvement. This is another area to
highlight participant strengths, document
specific needs, and explain the participant’s environment.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 8.01, 8.02, 8.03, 8.04Health services are unique to the
participant. These standards call for
information “as needed” however, if your
program requires health records they need
to be filled out as much as possible and noted if information is not relevant or not
applicable.
This information may also be found in other
locations such as assessments, screening
tools, or handouts. Copies of this
information is captured in the case file.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 9.01, 9.02, 9.03, 9.04Documentation shows that participants are
moving forward with skill building such as
relationships and networking both within
their family unit as well as within the
community.
Documentation tracks connections with
community resources, referrals and referral
follow ups, and the results of these
linkages. Use verbiage that explicitly
identifies how these standards are being met within documentation.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 10.02, 10.03, 10.04
Parent education is documented in such a
way that the curriculum used and the
activities provided are identifiable. Include
parent interaction and show family
interactions and responses. Documentation should reflect age appropriate interfaces.
Curriculum used and activities provided
relate to the participant’s self-identified
strengths. This is documented to show
progression.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 11.01, 11.03, 11.04Good documentation reflects the child’s
progression through assessments, age
appropriate and developmentally friendly
interactions and activities.
Document parent actions and reactions. Use
their own thoughts and words. Quote their
responses if possible.
As needed, referrals to outside sources of
developmental support are requested,
documentation will show how and when the
referral is made, follow up actions, and
results.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standard 13.01Good documentation reflects planning for
how things will look for a participant once
your program’s services end. This
conversation begins at intake and
throughout service planning. Tracking this information is to be clearly defined
throughout the case file. Records are to
include all entities involved in the
participant’s services as well as who the participant identifies as desired
contributors.
*Be sure that an aftercare plan is clearly identified and documented once the family begins to reach the end of services. This should be done whether the closing is planned or unplanned (when able).
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standard 14.07When outside entities are involved in
service delivery documentation is to reflect
the additional services, attainment, and
progress. Good documentation will also
reflect the relationship between all providers.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standards 20.01, 20.02
The participant’s rights are clearly defined
in documentation and include signed and
dated evidence that the client has received
this information. Participant rights are to
include the listed information here within 20.01.
Good documentation includes
accommodations for all levels of
functioning. These accommodations are
clearly recorded within the case file.
Let’s break down each standard that contributes to documentation.
Standards 21.01, 21.04
What Does Good Documentation Look Like?
Participants are made aware of mandatory
reporting status as well as duty to warn.
This information is clearly defined on the
participant’s level and well documented
within the case file.
Every case file reflects the use of a release
of information. Releases are used inside and
outside of the program. A release of
information is obtained at intake for any
and all alternate contacts the participant provides and throughout service delivery
when other agency services are required.
What Does Good Documentation Look Like?
Let’s break down each standard that contributes to documentation.
Standard 32.03Research may not impact every program
however every program is required to have
a well documented policy and procedure
regarding potential research. Should the
program’s policy on research change the participant is given information on the
research that outlines the requirements of
the standard and case files include signed
and dated documentation of this exchange.
Overview
Let’s not allow documentation to become overwhelming. Through proper and ongoing
training, programs and program staff can develop efficient documentation exercises that will carry them into successful and purposeful practices.
Questions?
IFSTAN Coordinator: Risa Ergenbright
Program Specialist: Leighann Mitchum
If you find yourself unsure how to document something please do not hesitate to ask, that’s what we’re here for!
