Documentation

What is Documentation?

Any physical or electronic note and/or record made by staff about

participants, specifically related to the services we are providing
them.
Why do we document?

1. To benefit our participants!

a. Improves their experience when staff changes
2. Keep staff informed
a. Makes working with participants easier
3. Provide a record of attendance and care provided
a. Who came to what program & when?
How does BPRD’s TR department use
documentation?
● K-Plan - Medicare Reimbursement
○ State receives federal funding to offer services for people
who otherwise wouldn’t have access to them
● Non K-Plan
○ Requests from 3rd parties
■ Legal situations
■ Assisted living
■ Employment
What does this mean for staff?

● In general
○ Quality documentation makes life easier for everyone
○ Better knowledge about participants
● Day-to-day
○ 5-10 minutes after programs
■ The sooner you do it, the easier it is!
○ Complete documentation ASAP after programs
The bigger picture

TR uses the APIE process…

● Assessment
○ Evaluate participant strengths/limitations
● Planning
○ Identify goals to improve upon limitations
● Implementation
○ Participants come to programs
● Evaluation
○ Are we moving in the right direction to achieve our goals?
 Assessment

● Helps to understand participant’s interests

● Used to evaluate participant strengths & limitations
● Helps to ensure good fit within groups
● Establishes a baseline
● Helps to identify areas for improvement
○ Goals & Objectives
Goals & Objectives

● Goals - What do we want our participants to accomplish

through our programs?
○ Ex. Follow directions on first prompt
● Objectives - Specifically how will the participant show they are
achieving their goals?
○ Ex. Participant will follow directions on the first prompt 4
of 5 times as observed by staff
Participant profiles
Things to consider when documenting

Subjective - What did we hear the participant say?

Objective - What did we see the participant do?

Assessment - What does this mean? How do these

behaviors/events relate to the participant’s goals?

Plan - What do we do next? Are we getting closer to achieving

goals? Could we be doing things differently?
Elements of high quality documentation
Clear & Concise

● Not vague
○ Jimmy had a good day in program today.
○ Jimmy actively participated in program and was observed
smiling throughout.
● Avoid “filler” words
○ So, just, very, that, etc
Complete & Descriptive

● Contains meaningful & relevant information

● Identifies source of information
○ Did you see/hear yourself?
○ Did someone tell you after the fact?
● Easy to interpret over time, even after long periods have
passed
Descriptive words

● Acknowledged ● Advocated
● Collaborated ● Conveyed
● Encouraged ● Developed
● Focused/Refocused ● Expressed
● Informed ● Facilitated
● Observed ● Interacted
● Reinforced ● Joined
● Supported ● recommended
Correct & Consistent

● Factual
● Accurate
● Non-contradictory
● Avoids duplication of information
● Based on observation, not opinion
Participant centered

● Includes subjective & objective data

○ What the participant does/says, what staff sees
● Relates to the specific needs of the participant (goals)
● Identifies problems which arise and actions to address them
What should our documentation
include?

● Description of events and behaviors involving our participants

● How these events and behaviors relate to their established
goals
● Variances from expected outcomes or established protocol
● Signature, date and title of program
● SIGNATURE, DATE AND TITLE OF PROGRAM!
Main takeaways

1. Quality documentation makes life easier for everyone.

2. The sooner you do it, the easier it is.
3. Helps us provide great services to our participants.
4. Focus on what happened during group - present the facts.
5. Reference participant goals.
6. Signature, date & title of program.
References
Guidelines for Medical Record and Clinical Documentation(pp. 1-16). (n.d.).
Retrieved June 6, 2019, from
https://occupationaltherapy2012.files.wordpress.com/2012/03/2007_guideline
s_for_clinical_doc.pdf

Hassan, N. (2017). CDI–Clinical Documentation Improvement (Impact on quality,

revenue development and recovery)(pp. 1-31). AHIMA. Retrieved June 6,
2019, from https://www.awc.world/wp-content/uploads/2017/11/Najla
Hassan - 2017 AWC ME HI Summit - CDI Presentation.pdf

Medical records and documentation standards. (n.d.). Retrieved June 6, 2019,

from
https://wa-provider.kaiserpermanente.org/provider-manual/working-with-kp/r
ecords-standards