IFSTAN Webinar Tuesday November 15, :00 am. Case Records & Documentation Standard 27

Transcription

1 IFSTAN Webinar Tuesday November 15, :00 am Case Records & Documentation Standard 27

2 Standard 27 The organization maintains a case record for each family that contains sufficient, accurate information to: identify the consumer; support decisions about interventions or services; and document the delivery of services. Interpretation: In addition to supporting the delivery of services, case records are an important risk management tool. Well-maintained records can help shield the organization from allegations of misconduct and negligence, while poorly-maintained records and improper documentation are known as a liability.

3 Let s break that down Case records are an important risk management tool. If it s not documented, it didn t happen! If it happened document it thoroughly and as soon as possible to maintain integrity. Well-maintained records can help shield the organization from allegations of misconduct and negligence. Well maintained records leave no doubt or room for interpretation or misinterpretation during file audits or during Peer Review. Poorly-maintained records and improper documentation are known as a liability. Documents missing information or inadequately filled out can be subjective and/or cause inadequacies in service delivery, be cause for ill preparedness of file audits, or legal issues should the agency/program be challenged.

4 27.01 Case records comply with all legal requirements and contain information necessary to provide services, including: demographic and contact information; the reason for requesting or being referred for services; up-to-date assessments; the service plan, including mutually developed goals and objectives; copies of all signed consent forms; a description of services provided directly or by referral; routine documentation of ongoing services; documentation of routine supervisory review; discharge or aftercare plan; recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and a closing summary entered within 30 days of termination of service.

5 Wait, what?! Forms that your programs use should be filled out completely. Required information should be gathered at intake, collected throughout service delivery, updated as needed, and maintained for the duration of services. Do not leave blank spaces. If information is unknown or unable to be obtained, note it so that documents are as complete as possible Interpretation: Describe the basic elements to be included in individual case records. We recognize that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record.

6 27.02 Case record entries are made by authorized personnel only, and are: specific, factual, relevant, and legible; kept up to date from intake through case closing; and completed, signed, and dated by the person who provided the service. There is no interpretation for therefore it is of the utmost importance to ensure that case records are meticulously cared for from intake through case closing and into aftercare.

7 Documentation During Peer Review During your peer review the reviewers utilize checklists in order to seek out required elements of documentation that meet the Iowa Family Support Standards. Particularly in documentation, reviewers are looking for documents to be filled out completely, dates information is documented, and that items such as assessments are completed at intervals that match your program s policy.

8 Sample Checklist

9 Note on the checklist that other standards appear. Documentation requirements can be met via many avenues throughout program practices and the Iowa Family Support Standards. Documentation can be found via; Intake Practices Screening Practices Assessments Service Plans Family Involvement How Needs Are Met Services & Education Progress Toward Self-sufficiency Referrals Case Notes To name just a few let s take a closer look!

10 A Closer Look Although Case Records live within Standard 27 there are inclusive documentation pieces throughout the Iowa Family Support Standards. These additional pieces will help your program complete documents and meet the requirements for Peer Review * * * * * * * * * * *13.01 * * *Some of these standards will be NA for Group Based Programs and Short Term Home Based Programs.

11 Standard 2.01 This is where you ll start to see the importance of keeping dates tracked and aligned with services. This will impact your peer review. Good documentation will show how your program addresses each of these points. Utilize your intake forms, screening tools, and any document the family signs.

12 Standards 3.02, 3.03, 3.04, 3.05 Specific and Factual Meet the participant where they are and document how it is done. Define and document resources used as well as the results. Assessments are always dated upon completion. Intervals should align with your program s policy. Ensure these documents are complete, up to date, and regularly maintained.

13 Standards 4.01, 4.02 Pay attention to details that lead service plans; dates, participant s goals/needs document who is present and who participates in the process. Document the participant s thoughts, quote their words, show how they lead the process. Highlight areas where participant s strengths are utilized, point out potential barriers and how to overcome them. SIGNATURES & DATES!!

14 Standards 6.01, 6.02, 6.03 Document participant s reactions to services, referrals, visits, interactions. Discuss and document participant s preferences to availability. Discuss and document participant s preferences regarding who is present during visits. Records will show a leveling or frequency system or the participant s requested service involvement. This is another area to highlight participant strengths, document specific needs, and explain the participant s environment.

15 Standards 8.01, 8.02, 8.03, 8.04 Health services are unique to the participant. These standards call for information as needed however, if your program requires health records they need to be filled out as much as possible and noted if information is not relevant or not applicable. This information may also be found in other locations such as assessments, screening tools, or handouts. Copies of this information is captured in the case file.

16 Standards 9.01, 9.02, 9.03, 9.04 Documentation shows that participants are moving forward with skill building such as relationships and networking both within their family unit as well as within the community. Documentation tracks connections with community resources, referrals and referral follow ups, and the results of these linkages. Use verbiage that explicitly identifies how these standards are being met within documentation.

17 Standards 10.02, 10.03, Parent education is documented in such a way that the curriculum used and the activities provided are identifiable. Include parent interaction and show family interactions and responses. Documentation should reflect age appropriate interfaces. Curriculum used and activities provided relate to the participant s self-identified strengths. This is documented to show progression.

18 Standards 11.01, 11.03, Good documentation reflects the child s progression through assessments, age appropriate and developmentally friendly interactions and activities. Document parent actions and reactions. Use their own thoughts and words. Quote their responses if possible. As needed, referrals to outside sources of developmental support are requested, documentation will show how and when the referral is made, follow up actions, and results.

19 Standard Good documentation reflects planning for how things will look for a participant once your program s services end. This conversation begins at intake and throughout service planning. Tracking this information is to be clearly defined throughout the case file. Records are to include all entities involved in the participant s services as well as who the participant identifies as desired contributors. *Be sure that an aftercare plan is clearly identified and documented once the family begins to reach the end of services. This should be done whether the closing is planned or unplanned (when able).

20 Standard When outside entities are involved in service delivery documentation is to reflect the additional services, attainment, and progress. Good documentation will also reflect the relationship between all providers.

21 Standards 20.01, The participant s rights are clearly defined in documentation and include signed and dated evidence that the client has received this information. Participant rights are to include the listed information here within Good documentation includes accommodations for all levels of functioning. These accommodations are clearly recorded within the case file.

22 Standards 21.01, Participants are made aware of mandatory reporting status as well as duty to warn. This information is clearly defined on the participant s level and well documented within the case file. Every case file reflects the use of a release of information. Releases are used inside and outside of the program. A release of information is obtained at intake for any and all alternate contacts the participant provides and throughout service delivery when other agency services are required.

23 Standard Research may not impact every program however every program is required to have a well documented policy and procedure regarding potential research. Should the program s policy on research change the participant is given information on the research that outlines the requirements of the standard and case files include signed and dated documentation of this exchange.

24 Overview Let s not allow documentation to become overwhelming. Through proper and ongoing training, programs and program staff can develop efficient documentation exercises that will carry them into successful and purposeful practices.

25 Questions? IFSTAN Coordinator: Risa Ergenbright Program Specialist: Leighann Mitchum If you find yourself unsure how to document something please do not hesitate to ask, that s what we re here for!