Frontline Initiative Documentation

Every Direct Support Professional (DSP) across the country should know how to effectively and accurately document, and why documentation is important when supporting individuals with disabilities. This issue of Frontline Initiative addresses the documentation process in its many forms such as, writing daily notes about how you are supporting an individual with disabilities, charting goals and objectives, and writing in staff communication logs.

All DSPs spend some part of their work day communicating through writing, or documenting. Howard Miller’s article, “Is Documentation a Necessary Evil?” suggests DSPs could make use of task analysis based on a step-by-step approach to any task by making a list of the steps a person would take to be successful at accomplishing their routines. Another approach to effective documentation is to create a portfolio with the person you support and help them record how they participate in each step of their goal using pictures, “to do” lists, and notes from phone contacts. Angela Amado’s article, “Is it Paperwork, or is it the Person?” reminds us about the importance of documentation from a person-centered approach — documentation becomes the person’s living history while DSPs come and go. Traci LaLiberte’s article, “Doing Documentation “Write,” covers the “how to’s” of documentation with hints and tips about how to write case notes effectively and accurately. Finally, DSPs should read the article on Health Insurance Portability and Accountability Act (HIPAA) and the importance of protecting information and data privacy. It is “need-to-know” information.

We also chose to include an article on DSPs in the Netherlands in this issue to acknowledge that a credentialing process and recognition for the work of DSPs is important worldwide. Finally, John Rose’s article, “DSPs: Building Bridges to Community, Choice, and Safety” offers advice on minimizing risk while promoting safety, choice, and self-determination.

After reading this issue, take some time to think about the documentation you do every day at work. What is really required by rules and regulations? What is necessary and what is helpful? When you write about the person you support, is it respectful and accurate? How do you protect the person’s privacy?