Frontline Initiative Documentation

Is Documentation A Necessary Evil?


Howard Miller is the director of training for REM Minnesota, part of the Mentor Network, Inc.

Few people would question the importance of documenting the services they provide to people on the job as a Direct Support Professional. If done correctly, documentation reduces errors in the administration of important medications. Documentation assures that people provide supports to individuals with disabilities in systematic and consistent ways. Documentation verifies that companies receiving public funds are spending them correctly for appropriate services. “Documentation” is unquestionably necessary. But, is it a necessary evil?

Documentation certainly has its “evil” aspects. People who could be providing supports are instead spending their precious time recording sometimes innocuous information. Employees are compelled to document bowel movements, menses and other highly personal information, intruding on the privacy of those they support. The adage “If it’s not recorded, it didn’t happen” is so entrenched in our minds that companies may emphasize recording information over actively supporting people. This is, unfortunately, not an unusual situation.

Most provider agencies must maintain licenses in order to continue offering supports to people with disabilities, yet the act of complying with documentation requirements may actually restrict their ability to offer adequate supports. This is especially true when funding is tight and staff-to-persons served ratios are lopsided.

Ironically the amount of record keeping staff are required to do is often related less to rules and regulations than it is to our own overprotective tendencies and failure to understand the reasons for documentation in the first place. One must exercise a well-cultivated sense of balance when dealing with documentation.

Here are some things to remember and practical steps to take —

  1. Avoid writing compliance objectives in individual program plans.
    • I always wondered why people kept repeating this phrase when talking about programming, “Never set achievement criterion at 100%. It’s a set-up for failure.” What part of crossing the street safely, I thought, would you not want a person to learn? Which step in self-administering a medication, or lighting a stove, or getting to the YMCA, would you want a person not to learn? Then I got it: these people weren’t talking about teaching others new things, they were talking about compelling people to do things that they already knew how to do! If you look at many individual program plans, you’ll find “compliance objectives” (e.g. Howard will carry out all steps of his morning routine 75% of the time). Hey, I don’t carry out all of the steps of my morning routine 100% of the time either! So, what’s the fuss? Well, if you’re butting heads (and documenting the encounters) over whether someone makes their bed in the morning or puts their clothes away in the evening, you are definitely wasting staff (and the person’s) time. Instead, just set-up the routine on a chart or graph, or have a reminder in a little book. Have the person monitor their own daily routines. Check the room from time to time. Have a celebration when the week is done and all the squares are red (or purple). People will get in the habit of minding their own affairs. Empower the individuals you support.
  2. Use task analysis as much as possible.
    • Many people see the use of task analyses as a retreat to the dreaded “medical model.” Task analysis is a method in which you break a task down into smaller steps and teach the person to learn the larger task by completing the various steps. Adversity toward task analysis is a case of guilt only by association. Task analysis forms provide a baseline and measure progress toward skill acquisition, while assuring that everybody teaches skills the same way all the time.
    • The task analysis should help the individual being supported to learn the skills they want to learn and should always be individualized. Develop task analysis by observing where the person will perform the task. Draft a step-by -step guide for the task as you would perform it.
    • Once the steps are in place, cue the person who’s going to be learning the skill to “make a hamburger” or “clean the living room” and see what they do. They may get a long way into the task before they need a single prompt! This is a good thing. Re-order as the person did them and then use this list to support the person in learning the task.
  3. Never document “programs” anecdotally.
    • Somewhere people started thinking that numbers were evil if they were used to document programs. It seemed that if you developed a goal for a person that taught them to do something they really wanted to do (e.g. “Bob wants to go to Branson and hear Donny and Marie”) it was much harder to document it numerically!

    • But it’s really not that tough to document reaching a dream. Think about all of the practical, functional steps along the way that could be learning experiences —

      • Calling travel agents

      • Checking the internet

      • Checking the paper

      • Making an itinerary

      • Making reservations

      • Banking for the trip

      • Buying clothes for the trip (watching the Weather Channel?)

      • Packing

      • Etc.

Interestingly, each step that Bob takes toward his dream vacation would produce notes, brochures, lists, articles, etc. — a quantity of documentation the gathering of which would not keep one employee away from active treatment for more than minute! Put these “documents” in a portfolio or album. Throw in the pictures of Bob with Donny and Marie. Goal achieved!

You’ll notice that survey-approved documentation was kept in the example above. The person was actually working on a real outcome. Staff direction and documentation was kept to a minimum, empowerment to a maximum! This is what should be getting documented! Let’s make life easier for DSPs by making it possible to professionally and directly support people.