Frontline Initiative Documentation
Doing Documentation "Write!"
Documentation has become an extremely important aspect of Direct Support Professionals’ (DSPs) work responsibilities over the past several years. DSPs are held accountable for what happens during the time that they are at work and providing supports to individuals with disabilities. One of the ways that supervisors, administrators, and government funding agencies keep DSPs accountable is through documentation. Therefore, it is essential that DSPs understand how to effectively document activities and incidents.
There are three critical components in effective documentation: 1) clear and concise content; 2) documentation completed in a timely manner; and 3) adherence to the seven basic rules of documentation. If a DSP is successful in following these three components, then the high quality of their documentation will contribute to the best possible support.
Clear and Concise Content
Clear and concise content must be at the forefront of a DSP’s mind when they begin to write information. Clear documentation is information that is recorded in a way that is easy to understand, straightforward, and uncomplicated. Concise documentation is information that is expressed briefly, while capturing all the facts and descriptions necessary for the reader to understand what occurred. There are two types of information recorded in documentation: objective documentation and subjective documentation. Objective documentation can be described as “just the facts.” In this part of your documentation, you would answer the following questions —
- WHO is involved? This might be the person receiving supports, someone providing supports, a family member, etc.
- WHAT happened? This is a brief description of what took place or didn’t take place, such as an individual participating in a community event.
- WHERE did the activity take place? It is important to be as specific as possible. For example, if you are documenting an accidental fall, it is essential to describe where in the home the person fell (i.e. at the bottom of the stairs that lead to the basement) and not just that they fell in the home.
- WHEN did the activity take place? Document the month, day, and year, as well as the time of day that you are making your documentation. Be sure to include AM or PM as part of the time.
Subjective documentation is the aspect of documentation where you, the DSP, can include your opinion. always indicate that this is your opinion. In this part of your documentation you would answer the following questions —
- HOW something happened. This is a description of how you believed that the event or incident took place.
- WHY something did or did not happen. In this area, you could make the following statement: “In this DSP’s opinion, Harry appeared to hit co-worker in frustration after this writer told him that his mother called to say she would be late to pick him up.” In this example, it is the DSP’s opinion that Harry was frustrated, but it isn’t a fact (objective documentation).
Complete in a Timely Manner
In addition to ensuring that your documentation is clear and concise, you must also be aware of the need to complete documentation in a timely manner. Documenting an incident or activity immediately (or soon as possible) after it occurs is optimal. Remember, if you don’t document that something happened, there is no record that it occurred. For example, if a person you support hit their head but told you they were fine and you failed to document the incident, and later that night they fell unconscious while with another DSP was providing supports, that DSP couldn’t tell the doctor of the earlier injury and the person’s medical care would be compromised. In contrast, documenting something that hasn’t happened yet isn’t good either. A DSP may think that they have a little extra time in their day and so they may want to do their medication documentation early so that after they give a person their medication the documentation will be done and they can leave for the day. This type of documentation is fraudulent and wrong. It is documenting something that has yet not occurred. Imagine if, following this documentation, the DSP forgot to give the medication. Other staff members would see the documentation and believe that the person did receive their medication. This could have serious results. Never document something before it happens.
Adherence to the Seven Basic Rules of Documentation
The last of the three essential components of good documentation is that the DSP follows the seven basic rules of documentation. These rules help to ensure that documentation is accurate.
- Write in dark blue or black ink. Do not use erasable pen or pencil because someone could change what you have written.
- Write legibly. Take your time and write neatly. The best information in the world is not useful if no one can read it! Don’t use abbreviations unless they are common in your agency and approved by your organization. Unknown abbreviations can make documentation difficult to understand.
- Always sign what you have written. This is your way to ensure that others know what you have and have not documented. Never sign something that someone else has documented and never document information on behalf of someone else.
- Be sure to include the full date with each documentation entry. This includes the month, day, and year.
- Document the time of your entry. Be sure to indicate if the time is AM or PM.
- If you make an error in your documentation entry, simply draw a line through the error and place your initials next to it. Do not erase a mistake or cover it with Wite-Out.® This rule helps to ensure that the entry is your own and that no one else has altered it (i.e. using white out).
- Use all the lines in the documentation log or book so that nothing can be inserted ahead of your entry. Do not leave room for someone else to document information. If they need to document something out of chronological order they can indicate that in the margin of the book. If there are unused lines in the documentation log or book, draw a single line across them so that nothing can be added.
These seven basic rules are easy to remember and follow. You may even want to cut out the simplified list below and post it in a visible location as a reminder. Most importantly, remember that the support provided to the people you support after you leave for the day may depend upon what you have written, so make sure that it is clear, concise, timely, and accurate!