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4.17 SCL – Documentation

Policy

A standardized format for documenting all individual services allows for more accurate communications among service providers.  The Personal Record for each individual will be organized and maintained in such a manner that all pertinent information can be documented and assembled routinely and in a timely fashion.

All information documented in records or logs is confidential and the individual shall have the right to approve or refuse the release of those records to any individual (including family members who are not court appointed guardians).  Individuals will be asked to sign a release of information for all staff and contracted service providers directly associated with Open Door the County Board of DD as well as any potential health care provider.

Procedures

Documentation of individual services will be maintained in a series of records and logs.  Information from logs and records is removed or “culled” by the program team member according to the schedule listed below. Documentation of individual services will be maintained in the following records and logs:

  • Brittco Goals
  • Brittco Medication Tracker
  • Behavior Data Sheets
  • LiveCare ONSEEN Consumer Ledgers
  • Individual Experience Forms

Personal Record Index

Brittco: ISPs, Support Documents and Documentation of Services

Brittco documents found in “Training” section of Brittco, “My Documents” tab

HeadingDocument Maintenance Schedule
Consumer Information ProfileUpdate at ISP
Social HistoryUpdate as needed
Psychological EvaluationUpdate as needed
Behavioral Assessment ReportOnly when separate from ISP

Brittco documents found in Goals Section

HeadingDocument Maintenance Schedule
Individual PictureUpdate per ISP Goals/Client Information “View ISP”
Current ISP/addendumsUpdate per ISP Goals/Client Information “View ISP”
Brittco “Goals” ReportsTracking/follow-up purposes

Brittco “Medication Tracker” Medication Administration Documentation (As prescribed by physician/scheduled by nurse), including but not limited to:

  • Scheduled Medication Administration
  • PRN Medication Administration
  • Temperature Checks           
  • Insulin/BS Checks/BP/O2/SpO2/etc.

Individual Chart Documentation

HeadingDocument Maintenance Schedule
Consumer Picture/SCL Quick Reference Contact ListUpdate as needed
Behavior Documentation SheetsPer BAR/ISP Span
Individual Mileage TrackingAssigned locations – current month
Narcotic Count SheetsAs prescribed/administered
Physician’s OrdersSigned POs/Current POs
Annual PhysicalComplete annually, maintain 2 years

Medical/Psychology/Counseling Appointment Sheets:

HeadingDocument Maintenance Schedule
Primary PhysicianMaintain 2 years
DentalMaintain 2 years
OptometryMaintain 2 years
NeurologyMaintain 2 years
PodiatryMaintain 2 years
PsychiatryMaintain 1 year
CounselingMaintain 1 year
Therapy (O.T., P.T., Speech)Maintain 1 year
Other SpecialistsMaintain 2 years

Other Social Services Documents

HeadingDocument Maintenance Schedule
GuardianshipTranscribed on Consumer Information Profile /SS files
Advance DirectivesTranscribed on Medication Tracker/SS files
Funeral PlansUpdate as needed/SS files

Other Medical Documentation

HeadingDocument Maintenance Schedule
Lab WorkAs ordered/HSC Nursing or Program Coordinator files
Hospital Discharge PaperworkPer discharge/Risk Management files

Finance Log Index: LiveCare Consumer Ledgers (digital)

HeadingDocument Maintenance Schedule
Personal LedgersPer expenditure
Petty Cash LedgerPer expenditure
Food Stamp LedgerPer expenditure
Spend DownPer expenditure
Debit and LedgerAdministrative/per expenditure
Joint Household LedgerPer expenditure

Instructions for Making Proper Entries

Paper Logs:

  • Service providers authorized to make entries as listed on each form.
  • Each entry is to be authenticated by the service provider’s signature, title, and date.
  • Initials must be identified on the form with the corresponding signature.
  • On some logs, individuals must verify service delivery by initialing or signing the entry of log.

Digital Logs:

  • Service providers authorized to make entries as listed on each form.
  • Each entry is to be authenticated by the service provider’s unique username and password used to login to document.
  • On some logs, service providers and individuals must verify service delivery by initialing or signing the entry of log.

Culling of Records

  • All Brittco records and logs will be culled by the Compliance Coordinator weekly for review/follow-up with DSP staff per incident of missed documentation.
  • All records and logs will be culled by the DSP/Lead/Program Coordinator per need/request.
  • Monthly Outcomes related to the “My Desired Outcomes” section of the ISP will be culled by the Program Coordinator/Lead DSP/DSP on the last day of the month, according to the culling schedule. This will provide for more continuity of services when reviewing the records at any time during the month.
  • Documents that are removed from the individual Charts will be turned in to SCL office monthly to be filed administratively.  Each log will have its own file and records will be placed in chronological order from the back to the front.  In other words, the most recent will be on the top.  Document will be kept in administrative storage kept by the SCL programming team for (1) year, at which time the appropriate documents will be sent to long term storage as needed.
  • Financial Logs will be kept digitally when possible. The Software Administrator will follow-up on all LiveCare Consumer ledger alerts and provide counsel as needed to aid DSPs in completing documentation accurately.
  • Documentation filed in the home and in the SCL office will be stored for seven (7) years.

Security and Release Information

  • All disclosure of information must be accompanied by the signed consent of the individual.
  • Records and logs will not be taken off of the individual’s property except for the purpose of delivery of services.
  • Records and logs must be stored on a designated shelf in each home in an area that is not conspicuous to visitors.

Last Revised: 8/25/21

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