Illinois Guidelines for Effective Documentation

Course Code: REL-IDD-OADSP-ILGED-V2

Hours: 3

Type: Online Course

Content Expiration Date: 9/30/2023

Learning Objectives:
Describe legal and ethical standards for sharing personal information about the person you support
Examine documentation guidelines for use by staff at your agency
Develop strategies for managing documentation duties

Outline:
Section 1: Introduction A. About This Course B. Learning Objectives Section 2: What We Document and Why A. Collin’s Emergency B. The Community Support Skill Standards Related to Documentation C. What is Documentation? D. What Should Your Documentation Include? E. The Purpose of Documentation – A Full and Safe Life F. What to do? G. How Is Documentation Beneficial? H. For Documentation To Be Beneficial It Must Be Reviewed I. Consider Content J. Section Summary Section 3: Direct Support Professional Roles and Associated Documentation A. Medicine, Health Care Appointments and Health or Medical Changes B. Preventative Health Screening Documentation C. The Person’s Plan and Tracking Progress D. Unusual Incidents and Accidents E. Writing an Excellent Incident or Accident Report F. Documenting Communications G. Communication Log Book Entries H. What is Wrong with This Entry? I. Financial Management J. Under Suspicion K. Assessments L. Juggling Important Duties with Documentation Requirements M. Organize Your Charts and Files N. Coping with the Paper O. From Piles to Files – Creating a Filing System P. Reduce Paper and File Documents Electronically Q. Section Summary Section 4: Guidelines for Effective Documentation A. Legibility, Dating, and Timeliness B. Drop the Jargon and Show Some Respect! C. Documenting Facts, Not Assumptions or Opinions D. The Case of the Wet Head and Bloody Nose E. Correcting Your Mistakes and Handling Gaps and Spaces F. Subjective Vs. Objective G. Section Summary Section 5: Confidentiality and Ethical Practice A. What is Confidentiality? B. Respect and Dignity C. Claude’s Embarrassment D. Avoiding Breaches of Confidentiality E. Informed Consent and Releases of Information F. Exceptions to Obtaining a Written Release of Information G. When Violating Confidentiality is Okay H. Aaron’s Dilemma I. Section Summary Section 6: Conclusion A. Summary B. Put Into Practice C. Congratulations

Instructor: Deb Easley, M.S.

Deb Easley, M.S. is the Training Coordinator for Living Arrangements for the Developmentally Disabled, Inc. (LADD, Inc.) in Cincinnati, Ohio where she has worked for the past 18 years. Deb is one of the founding members of DSPATHS Credentialing Program and Ohio Alliance of Direct Support Professionals (OADSP). Her experience with DSPATHS includes being a Regional Manager, Instructor, Skill Mentor, Regional Coordinator, Regional Financial Administrator, Statewide Operations Administrator, and Curriculum Writer. Deb holds a Master of Science degree in Health Planning and Management and a Bachelor of Science degree in Education. Deb has personal and professional experience with the social and health issues encountered by people with disabilities and their families. Disclosure: Deb Easley, M.S. has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.

Target Audience:
The target audience for this course is: Entry level Direct Support Professionals; in the following settings: Intellectual Developmental Disabilities.

Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.

Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.