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Also See DH Special Services Independent
Study Program:
Documentation
Techniques for the Activity and Recreation Professional
NCCAP approved 10.5 contact hours
Documentation
: What's the Point?
The
process of documentation can be a stress provoking process for
many activity professionals. We know it is important, but who
has the time?
Entering
information about the resident or client is a responsibility
many professional care givers share. It is also a privilege
to be a part of the team which is involved in assessing the
resident or client's needs and developing treatment plans to
provide appropriate care and services.
Knowing
this is important for anyone involved in the documentation process.
Knowing why we document - is the first step.
Communication : It would
be wonderful if we could sit down with all involved professionals
and discuss resident/client care at length, on a daily basis.
However, that's not possible in most cases. The medical record
can be a communication link between professionals. This is a
major reason why all entries should be accurate, timely and
written in a professional manner.
Justification : Although
the profession is guided by standards of practice, each resident/client
is an individual. Sometimes interventions work and other times
they do not. Documentation which chronicles interventions offered
and resident/client response provide the department with justification
as to why the current plan of care is in place.
Continuity
of Care : Our main goal in caring for our residents/clients
is to ensure quality care and services. In some cases, multiple
staff care for the resident/client within a department. Documenting
pertinent information, treatment plans and response to care
can act as a guide for staff to follow. This prevents repeating
unsuccessful efforts, maintains successful approaches and permanently
records individualized information the resident/client provides
upon admission.
Accountability
: "If it isn't documented, it isn't done!" is a common
response as to why documentation is important. There are regulatory
requirements defining certain entries which is what this common
perception is based upon.
What guides the documentation
process?
Who makes the "rules"?
There
are two supporting factors which define and direct required entries.
Legal
Factors : Regulations! Health care settings are defined through Federal and State regulations. The activity professional should
become familiar with the regulatory agencies that govern their
facility. The regulations will clearly define which entries are
required, time frames for completion and in some cases, actual
content.
Professional
Factors : Each profession is guided by Standards of Practice.
The National Activity
Professional Association, The
National Therapeutic Recreation Society and the American
Therapeutic Recreation Association all have written Standards
of Practice. They clearly define documentation standards and content.
Being affiliated with a professional organization provides access
to this information which can further guide the professional in
appropriate documentation content.
General Medical Record Guidelines
*Sign
all entries with full name, job title, and date.
*Never
use white out.
When an error is made, cross it out with one line, write "error"
and initial.
*Use
only approved medical abbreviations.
*Write
legibly; and ensure spelling and grammar is correct.
*Use
black ball point pen.
*Do
not skip lines. If open lines are left,
they need to be crossed out before the next entry.
*Be
accurate, concise and factual.
Stay away from generalized judgments which are vague.
*Be
aware of facility policy regarding medical record
guidelines, use of forms and individual entries.
Main
Tip Page
Documentation
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