UNIVERSAL LOGGING GUIDELINES I. Charting (whether electronic or paper)
- Be objective or identify statement as opinion.
- All logging should be detailed and complete.
- Logging is factual and sequential
- Logging is done at least one time per shift or if significant occurrence(s) take place.
- Any late entries documented as such.
- Document month, day, year, first initial, last name, job title.
- Cross-reference when appropriate (i.e., see health care notes)
- Chart on level of independence, assistance or intervention needed (i.e., verbal cue, gesture, physical assistance, and observation).
- Use correct spelling (refer to dictionary, if needed).
- Legible handwriting on paper copies.
- Use direct quotations when appropriate (i.e., “No, I won’t”).
- Paper Charting Only
- No white out or obliteration of mistake-errors on paper copies should be crossed out with a single line (allowing error to still be legible), noted as “error” and initialed by author.
- Do not skip lines on paper copies.
- Document on paper copies in permanent black or blue ink as the log is a permanent record.
- Logging on paper copies should begin at very top of page leaving no extra space or margin. The last entry on page should go to very bottom of page.
- Overall Content
- Group activities-in-house/community, including supervision/assistance needed and response to activity.
- Peer interactions/friendships
- Social behaviors exhibited (positive or negative)
- Social etiquette
- General mood/affect
- Response to staff requests
- Maladaptive (i.e., SIB’s, property destruction, profanity)
- Behavior with peers, staff, family, etc.
- Vulnerability exhibited
- Quality of sleep
- Socially inappropriate withdrawal, aggression, stealing, hoarding
- What led up to any noted behavior and staff follow-up
- Personal Care
- Level of independence/assistance needed (verbal, physical, etc)
- Dressing (weather/occasion/appropriate)
- Care of personal belongings
- Daily living skills
- Domestic responsibility
- Money management simple/complex
- Follows daily routine
- Self-preservation (strengths/needs) in emergencies
- Community/transportation skills/safety skills
- Cooking/meal preparation simple/complex
- Household safety (i.e. response to drills, etc)
- Problem solving skills (initiation, identifying, alternatives, asking for assistance when appropriate)
- Handling consequences or not of decisions made
- Assertiveness skills
- Skills in various settings (home, work, community)
- General Health
- Medications-compliance/independence/staff assistance needed
- Medical appointments-behavior at/independence, staff assistance required
- Health complaints or body language indicating concern
- Need for clinical monitoring/specific condition (acute or chronic)
(Document general comments about communication that was or was not exhibited, whether verbal or non-verbal)
- Progress on goals
- Interest/cooperation with programs
- Specific successful approaches found
- Future program needs/ideas
Documentation has 3 primary purposes:
- To communicate essential information to other team members
- To provide a written record of treatment as well as the facts and reasoning behind the treatment
- To ensure quality care
Documentation errors defeat the purpose of documentation. Some documentation errors are
Documents are a legal record
- Omission of information
- Use of terminology that others do not understand or slang
- Unprofessional comments about coworkers or describing a person served in a negative way
- Recording opinions instead of facts
- What if you didn’t document thoroughly and accurately?
- According to www.medicalassurance. com, “documentation is the most important aid in the defense of liability suits and the most decisive evidence that the Standard of Care was met.
- The issue of liability suits center around whether the “Standard of Care” – which is the legal yardstick used to measure our legal duty to a person served – is measured.
- Keeping good and thorough records is essential to defend against negligence. It is one of the most important responsibilities of your job.
Error’s and HIPAA
- When you need to correct an error made while documenting, draw a line through the error, write “error” and your initials above the line, and then write the correct information
- For omissions, make a late entry in the current record. Include the current date and time you are making the entry, the date and time you are making the late entry for and the omitted information.
- The documentation done by direct service staff is protected by rules of confidentiality and HIPAA. That means we can only disclose “Need to Know” information and cannot disclose information that does not fit the categories of Routine/Recurring Events, Non-Routine/ Recurring Events Not Requiring Authorization or if there is not a HIPAA disclosure. Additionally, there is the requirement to protect documentation by keeping records in a secured location where others who are not involved with the person’s care cannot access the records.
GER’s and Incident ReportsA General Event Report is a tool used for documenting significant events that have occurred in the program. This includes medical incidents, behavioral incidents, and events such as the theft from individuals served. Incident Reports are for Staff injuries, theft of staff belongings and anything else related directly to staff but not the client.The following situations require a GERInjury, illness or a medical issue
that requires medical attention. This includes cuts, scrapes or bruises even if they appear to be minor and/or the cause is unknown. Additional steps:Call supervisor; if after hours and injury is minor, leave voice message. If injury is major, contact on-call supervisorDocument in T-LogSend an SCommAn individual is missing
. Additional steps:Check premise to verify presence of other persons servedNote when the individual was last seen and individual was wearingCall supervisor or on-call supervisorContact police and file a missing persons report; stress individual is a “vulnerable adult.”Document in T-LogA medication error
has occurred. Additional steps:Document in the T-LogsIf it is a pharmacy error, contact the pharmacy.An individual refuses medication
. Remember, 3 attempts must be made to administer medication before marking it as refused. Additional steps:Document on the MAR in TherapDocument in T-LogNote in SCommMedication is accidentally destroyed
i.e. fell down the sink. Additional steps:Document in T-LogNote in SCommDocument on Medication Destruction/Return to Pharmacy Record form (MD3-08)Contact pharmacy to arrange for replacement of medicationAdminister pill from last day of month in bubble pack to allow pharmacy time to replace destroyed medicationAn individual is demonstrating odd or destructive behaviors
. Additional steps:Document T-LogContact SupervisorA person served hurts another individual
. In such cases, 2 GER’s need to be completed: one for the assailant and one for the individual injured. Do not record one individual’s name in the records of another person. Instead you can state, “John injured a peer.” Additional steps:Document in the T-Logs of both individualsAbuse or neglect
is witnessed or suspected or an individual’s rights have been violated. Additional steps:Call supervisor or on-call supervisor if after business hoursFollow Policy and Procedure Concerning Individual Abuse and Neglect
(B-12).There is exposure to blood or bodily fluids
. Additional steps:Wash area immediatelyCall supervisor or on-call if after business hoursComplete exposure packetIf person supported is exposed, document in T-Logs, inform staff.Staff is injured at work
. Even if injury appears to be minor, an Incident Report must be completed so that in the event a major problem develops later, the Incident Report is available as verification of the injury. Additional steps:Call supervisor or on-call supervisor immediatelyThere is a car accident or damage
to a car. Call supervisor or on-call supervisorFor accidents. Contact the police. Don’t admit fault. Exchange insurance information with the driver on the other car. Complete a Vehicle Accident Report Guide (A1-81)If a person served or staff member is injured in the accident, a separate Incident Report or GER must be completed for each individual hurt.Injuries to persons served must also be recorded in the individual’s T-Logs Death of a person served
. Additional steps:Call 911 immediatelyContact supervisor or on-call supervisorDocument in T-Logs the actions taken in response to discovering individual, i.e. the initiation of CPR.Write GER