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
| Heading | Document Maintenance Schedule |
| Consumer Information Profile | Update at ISP |
| Social History | Update as needed |
| Psychological Evaluation | Update as needed |
| Behavioral Assessment Report | Only when separate from ISP |
Brittco documents found in Goals Section
| Heading | Document Maintenance Schedule |
| Individual Picture | Update per ISP Goals/Client Information “View ISP” |
| Current ISP/addendums | Update per ISP Goals/Client Information “View ISP” |
| Brittco “Goals” Reports | Tracking/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
| Heading | Document Maintenance Schedule |
| Consumer Picture/SCL Quick Reference Contact List | Update as needed |
| Behavior Documentation Sheets | Per BAR/ISP Span |
| Individual Mileage Tracking | Assigned locations – current month |
| Narcotic Count Sheets | As prescribed/administered |
| Physician’s Orders | Signed POs/Current POs |
| Annual Physical | Complete annually, maintain 2 years |
Medical/Psychology/Counseling Appointment Sheets:
| Heading | Document Maintenance Schedule |
| Primary Physician | Maintain 2 years |
| Dental | Maintain 2 years |
| Optometry | Maintain 2 years |
| Neurology | Maintain 2 years |
| Podiatry | Maintain 2 years |
| Psychiatry | Maintain 1 year |
| Counseling | Maintain 1 year |
| Therapy (O.T., P.T., Speech) | Maintain 1 year |
| Other Specialists | Maintain 2 years |
Other Social Services Documents
| Heading | Document Maintenance Schedule |
| Guardianship | Transcribed on Consumer Information Profile /SS files |
| Advance Directives | Transcribed on Medication Tracker/SS files |
| Funeral Plans | Update as needed/SS files |
Other Medical Documentation
| Heading | Document Maintenance Schedule |
| Lab Work | As ordered/HSC Nursing or Program Coordinator files |
| Hospital Discharge Paperwork | Per discharge/Risk Management files |
Finance Log Index: LiveCare Consumer Ledgers (digital)
| Heading | Document Maintenance Schedule |
| Personal Ledgers | Per expenditure |
| Petty Cash Ledger | Per expenditure |
| Food Stamp Ledger | Per expenditure |
| Spend Down | Per expenditure |
| Debit and Ledger | Administrative/per expenditure |
| Joint Household Ledger | Per 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
