4.17 ICF – Location Communication and Documentation Systems
Located on the Electronic Software where notes, appointments, community experiences and upcoming information is located will access to all location employees.
Documentation is required to be completed each shift for every individual that the staff provides care to, if more than one staff works during the specified shift they should only document on tasks they completed. Staff who are pulled into an apartment to work should review the documentation as well as the individuals’ PCP/goals. At the end of each month the QIDP will pull the documentation for storage. The ADL’s, BSP preventatives, BSP data collection, and programs/goals report will be printed as needed.
- Bowel/bladder activity – staff should document on the ADL the number and size of each bowel movement by the individual during each shift and document. For urinary incontinence document the number of incidents during each shift and for individuals with catheters document the number of CC’s emptied from the catheter.
- Meals – staff should document the percentage of each meal/snack consumed per the menu, substitutions should be documented on the substitution form. Anytime an individual refuses a meal, staff should contact the nursing department and document the refusal on the ADL.
- Outings – if an individual leaves the apartment for an outing staff should document under the Community section on their ADL sheet.
- Medical incidents – if any of the specified medical incidents such as a fall, skin breakdown, injury, or illness were noted during the shift; staff must call the Nursing Department, Risk Management, and then an Accident and Incident (A&I) must be completed if instructed by Risk Management.
- Behavioral incidents – if an individual engages in inappropriate or maladaptive behaviors during the shift it should be documented on the BSP data collection sheet. If it is a new behavior not outlined in the PCP/goal, Risk Management should be called and an A&I completed. Staff are also required to document on BSP preventatives each shift as well.
- Medical appointments – medical transportation is responsible for setting up each individuals’ medical appointments each week and placing it on the electronic calendar. All appointments are documented in electronic software for tracking purposes.
- Active Treatment Schedule (ATS) – outlines each individuals’ typical daily routine, they are maintained electronically and can be accessed by all staff via the electronic software on the computer in the apartments.
- Dietary information
- Each individual has a placemat kept in the apartment kitchen which includes the following information: diet, texture, adaptive equipment if applicable, and eating strategies.
- Menus, substitution forms, and recipes are maintained electronically and are accessible via the computer in the apartment and staff should document on the substitution form accordingly when necessary.
Last Revised: 4/30/21