Detailed Documentation Best Practices

Discuss the level of independence and success achieved in completing each task: •Identify each of the documentation tasks completed •Identify the purpose of documenting in each situation •Identify method of documentation used (i.e. soap, narrative, DAR(P), locally created procedures etc.) •Discuss the student level of independence and success achieved in completing each task i.e. assisted supervisor, required assistance, independent. *Helpful hint – refer to Monica’s Assessment & Documentation class for (Purpose & Methods) & Stumbo & Peterson Textbook* Answering the Competency Checklist 2. a) Agency Policy & Procedure: •Identify and explain the agency’s policy and procedure(s) to record useful data in a clear, professional, and accurate manner. (i.e. methods, confidentiality, privacy rights, when to, how often) •Each agency completes documentation slightly differently. •What specific requirements are followed at the agency? (is there a formal policy or unwritten rules) •Who is responsible for completing documentation? (management, RT’s, all staff) •Explain how important documents are organized, stored and archived? (locked files, secure electronic system). Answering the Competency Checklist b) Range of Documentation: •Identify and explain the full range of documentation processes and forms used by the agency. (intake assessments, case review, discharge summaries, intervention plan, program evaluation, progress notes, incident reports etc.) **See list of examples on next page** •Be sure to include only a range of documentation that is completed by RT’s at your agency. Each agency may have different forms that are completed by RT’s that are not Recreation specific but is part of their job. •Identify each documents purpose, and timing (when each document is completed i.e. As needed, every 3 months, upon admission etc.…) Answering the Competency Checklist b) Range of Documentation: •Examples of documentation that may occur at your agency: •CCAC Referral Form Admission Chart Intake Assessment •Care plans / Quarterly Assessments Progress Notes / Chart Notes Leisure •Assessment •Program Attendance •Program Evaluation •Resident / Patient Discharge / Transfer •Photo Consent Form •Death Record Answering the Competency Checklist c) Documentation Tools: •Identify and explain documentation tools used at the agency. (i.e. technology, computer programs, client chart, pen and paper etc.…) •What type of computer documentation programs are utilized by the agency? (Some agencies may not use computer documentation) d) Negligence and Documentation: •Identify and explain the risk of harm if documentation is incorrect, subjective, inconsistent, unclear, or misunderstood. •What happens if an error is made? Is there a penalty, suspension, termination, education? •What are the consequences & what is the risk of harm? (death or injury) Review Rubric •Rubric available on MyCanvas •Review rubric as you work on the assignment •Ensure you have included all required items that are noted in rubric to receive full marks The final documentation should be prepared as a comprehensive report.