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Complete documentation, including writing or amending an individualised plan Contents Comply with the organisation’s reporting requirements 2 Your role in complying with the organisation’s reporting requirements 4 Maintain documentation in a manner consistent with reporting requirements 6 File documentation organisation policy and protocols 10 Storing and maintaining information electronically 10 Folder heading system 12 References 13 Websites 13 Other resources 16 Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 1 © NSW DET 2009

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Complete documentation, including writing or amending an individualised plan

ContentsComply with the organisation’s reporting requirements 2

Your role in complying with the organisation’s reporting requirements 4Maintain documentation in a manner consistent with reporting requirements 6

File documentation organisation policy and protocols 10Storing and maintaining information electronically 10Folder heading system 12

References 13Websites 13Other resources 16

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 1© NSW DET 2009

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Comply with the organisation’s reporting requirements

Records are essential for the successful implementation of a person’s long-term plan. To be successful, an individual plan (IP) requires ongoing continuity with implementation and a clearly-identified and documented basis for future planning.

Records must provide the following:

background information necessary to assess the service user’s needs (to facilitate information gathering in the pre-IP planning phase)

a means of monitoring the service user’s progress so changes can be made to program(s), when necessary

a basis for review and evaluation of the effectiveness of programs

checks to ensure individual planning is happening

information about what services are being provided to whom, where and when

a facility for monitoring the quality and cost effectiveness of services

a record that can form the basis for policy decisions and recommendations

The Standards for disability workers are contained within the Disability Services Act 1993. Under Standard 8, Section 1 (Structure and function of the governing body) talks about the reporting responsibilities of the organisation. This is reproduced in Figure 1 on the next page.

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The governing body ensures all annual and cyclical reporting, as required by the Agency’s legal status, is made to external bodies, membership and service users.

The governing body ensures the Agency’s annual report includes information on the Agency’s performance measured against identified objectives.

The governing body ensures minutes of all Board meetings, signed by the chairperson and in chronological sequence, are kept.

The governing body ensures a regular reporting process for financial and risk management is implemented.

The governing body ensures that an annual report of its service and financial activities is produced and made available, as appropriate, to the Ageing and Disability Department, service users, families, staff, members, donors and all other interested people.

The governing body ensures a process is developed to carry out the assessment of its services each year, as required by the Continuation of Funding Package.

The governing body ensures the Continuation of Funding Package for each project of the Agency is completed each year and returned to the Ageing and Disability Department by the due date.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 3© NSW DET 2009

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Where necessary, the governing body ensures opportunities and independent facilitation or support, are provided to enable service users to be involved in the annual assessment process.

Source: Standards in Action

Figure 1: Reporting responsibilities of the service organisation

The way an organisation can put their reporting responsibilities into practice includes:

using a consistent agenda for all meetings of the governing body, subcommittees, working groups, service users and staff

presenting papers and reports in clear and concise language and distributing them for consideration before a meeting

ensuring there is sufficient time in a meeting agenda for its service user advisory committee to present a report

encouraging the service user advisory committee to consult with other service users to provide feedback for annual assessment

ensuring the disability services standards are used to focus explanations about changes and developments during staff meetings

including its philosophy statements in its information brochure, annual report, strategic plan and fundraising material. The statements are translated into the main language of the local community.

It is a funding requirement that the organisation have effective policies and procedures on information systems which include:

systems for collection and storage of information that observe the privacy, dignity, confidentiality and security needs of clients and staff

appropriate systems for accountability, documentation, information management and storage

identification of legal documents and how they are handled and accessed

consistent storage, archiving, access to and destruction of all types of documents

is timely, reliable and valid collection of information that meets any reporting requirements.

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It is a legal requirement that professional documentation of all aspects of support for a client be completed. Everything recorded in relation to supporting a person with a disability is a legal document and may be used as evidence in a court of law. These records can be subject to close and careful scrutiny.

Your role in complying with the organisation’s reporting requirements In the community services industry you will be required not only to provide ‘hands on support’ to clients, but also to fill in forms and write reports concerning that support. An understanding of records is critical to your work role since it is these records that will give you the necessary information to appropriately support people with a disability.

It is important that accurate records are maintained in the process of designing individual support procedures, especially for the evaluation and review process. There are many reasons for this but a very important reason is that the information gathered can be used for further learning opportunities in planning, for designing individual support procedures and for changing part of the design where necessary.

Your records will show you how well the client is progressing and also what aspects of the plan may need to be changed. For example:

The client is not responding to a strategy that will help meet their goal and a new way may need to be investigated.

The client may not get enough practice, possibly because there is too much time between teaching sessions.

The client’s goals may have changed or their life circumstances may have changed.

There will be many reasons why a client is not making progress towards their goal. They could be external to the teaching process, for example:

the client may have some personal problems that may be causing distress

there may be environmental barriers.

It is important to be aware of such factors and to try not to put too much extra pressure on the client. The problems that are preventing the goal from being achieved needs to be looked at and perhaps new strategies need to be implemented. Only by documenting these issues are we able to make these decisions.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 5© NSW DET 2009

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This would be a good time to attempt Activities 1, 2 and 3 before moving on with the remainder of this reading.

Maintain documentation in a manner consistent with reporting requirementsHealth and community services records are permanent, legally accountable documents that must accurately record client needs, the actions of the worker/s concerned and general service delivery practices.

These records may be produced in court to substantiate or refute client claims, to support funding submissions, and/or to measure service outcomes and quality care provisions.

Organisations and agencies usually have guidelines and procedures about correct documentation methods. Workers need to comply strictly with these organisational requirements.

To find out about an organisation’s policies:

ask your supervisor or work based learning coordinator

look at the organisation’s policy and procedures manual

ask other staff members

inspect current case files, letters, etc if you have permission.

You have a responsibility to find out what the organisation expects and then abide by the rules. If you don’t agree with the organisation’s guidelines and procedures, you need to discuss your concerns with your supervisor.

In general however, follow these basic rules outlined below.

Written reports

Reports, regardless of their particular written form (eg charts, progress notes, must be:

legible—print if your handwriting is unclear

written in plain English

include the date and in some instances the time of each entry

identify the person’s family name, first name, date of birth and medical record or client number

stored for seven years after the person ceases to receive services.

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Legal implications

CSI and health documentation can be subject to close and careful scrutiny during civil (allegations of negligence) and criminal legal proceedings and therefore must reflect a professional approach. Documents must be:

accurate

objective

legible

brief and complete.

Written records are ‘legally accountable’ and therefore the person who gives the care must record their actions or observations factually. Do not use yellow sticky notes, these get lost, do not write in pencil, do not erase entries, and do not leave spaces between entries to write things in later.

Record all the important issues but do not ‘pad out’ the record with non-essential information.

Workers often need to gather and record information about a person to assist in the development, monitoring and evaluation of service plans. Be observant, this will help in the early identification of potential problems. Document needs and problems, but especially document any changes in the client and/or variations in normal service delivery.

Alterations and errors

Errors must be appropriately corrected. The original (incorrect) entry must still be legible after the correction. The health care worker making the correction rules a single line through the incorrect entry, and initials it. The correct information is then written legibly next to the error.

There are to be no spaces between individual health care worker reports. This ensures that information cannot be added at a later stage.

Do not use correction fluid to correct errors.

Do not use water soluble ink, red or blue pens or pencils.

Other record-keeping issues

As disability support workers, we are accountable for the service we provide to our clients and the service for which we work. We are also accountable for keeping all forms and documentation up to date, with review dates etc, and implementing those reviews. One way of being accountable and ensuring reviews take place is through record keeping. Record keeping also provides us with the baseline information we need to monitor how effectively and consistently a plan is being implemented.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 7© NSW DET 2009

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While monitoring happens regularly, there are significant times when it needs to be considered, such as:

when timeframes specified in the IP have been reached

at times of change (eg, goals have been achieved)

at times when available resources change (eg, staff levels are different, support networks change)

if the person requests a review.

There are a number of issues to be aware of in record keeping:

Confidentiality: Information in these records of a person’s life will be very personal in nature. So they should be kept in a secure location where only those people who need to view can do so. The location where they are kept needs to be secure.

Language: Language used in these files should be non-judgmental and positive. Remember that the person who the records are about should be able to read them without feeling insulted. It is a good idea to keep records jargon-free as well, so everyone who reads them will be able to understand them. Don’t forget your writing needs to be clear and legible as well. The organisation you work for may have standards that are required of you with regard to this.

Identification: As previously mentioned, you are accountable, so records you are completing should clearly state your name and signature and the date. They should be arranged in an ordered way so access to different forms is easy.

Accuracy: Your records should only contain facts. If you include information about what you feel or believe, then you must state this. Don’t use language such as ‘Joey doesn’t like working with Hamish’ because you observed Joey getting irritable with Hamish when working with him in the youth program. Instead, you could state, ‘Today I observed Hamish looking confused when Joey got annoyed with him’: this is fact. You could add, ‘I am concerned that possibly Joey doesn’t like working with Hamish, I will need to investigate further’: this is a feeling.

Including the person’s views and goals, and those of the significant others in their life: Make it easy for the person to have an opportunity to have their own entries in the records, and allow them to challenge and change entries you may have made.

It is most important that the person consents to information being shared about them. Having the person or someone responsible for them sign a consent form acknowledges that permission has been granted to do so.

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This would be a good time to attempt Activity 4 before moving on with the remainder of this reading.

Accuracy

It is very important that records are accurate at all times and completed in identified timeframes.

Things to do:

Ensure the client’s name is on all pages.

Check the client’s name on the record before making an entry.

Write date and time on all entries.

Make sure entries are in chronological order. That is, date and time of reports must follow on, with no gaps between reports.

Document what you observe and do for the client.

Be brief and complete about issues relevant to the clients’ support.

Document events and observations as they occur to minimise confusion of the events.

Things not to do:

Do not write reports on behalf of other workers.

Do not use abbreviations which are not widely acceptable by the organisation.

Do not use words you do not know the meaning of.

Do not document events witnessed by others as factual if you did not witness the event yourself.

Ensure your reporting is accurate. For example, do not write, ‘Mr Miller was assaulted by another client’ if the correct entry should read, ‘Mr Miller stated he was assaulted by another client’.

Legibility

Things to do:

Write the documents clearly to avoid mistakes.

Printing may be an alternative when handwriting styles are not easy to read.

Write reports in English.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 9© NSW DET 2009

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Draw lines through errors using a ruler and initial the change. The original incorrect record must remain readable.

Document using a black ballpoint pen only to avoid smudging.

Use correct spelling, punctuation and grammar at all times when documenting.

Things not to do:

Do not use correction fluid to correct errors.

Do not use water soluble ink, red or blue pens or pencils.

Comprehensiveness

Things to do:

Consider the readers of your documents.

Check previous entries for continuity of support and follow-up action.

Consider the purpose of your records (eg are you reporting what you have observed or found, are you presenting ideas or recommending actions be taken).

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File documentation organisation policy and protocols

Storage is often a complex issue and can be the source of hot debate within organisations. The government, for instance, has whole warehouses of stored information. Smaller organisations often store information on-site or at storage houses.

This would be a good time to attempt Activity 5 before moving on with the remainder of this reading.

Storing and maintaining information electronicallyIncreasingly, community service organisations are storing information electronically. This saves paper and storage costs, and can be accessed securely and easily by a number of staff. But, like a manual system, there is a need to have an organised way to store and access the information. Some organisations now have quite a sophisticated system including shared files and Intranet. But whether you are working in a small or a large organisation it is vital that there is a system for storing information that all staff understand and can access. The system is usually written about in the policies and procedures manual.

You will need to know or be able to learn how to set up electronic files, save them and put them in folders. Most organisations now use individual passwords for staff to access their individual computer or the organisation’s computer network. This ensures security of information.

You need to consider the rights of clients in being able to access their information. Does the person require computer literacy to access their own information or are they reliant on a worker for their password? This is where hard copies are useful as a backup.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 11© NSW DET 2009

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Creating and accessing files

At a basic level, workers are often expected to create a file, save it and then access it again to make changes to it. Once you can do this, it makes writing so much easier.

This would be a good time to attempt Activity 6 before moving on with the remainder of this reading.

Password

When you deal with confidential information that you are storing on computer, it is important that you have a password. This means that someone else cannot access the information on your computer. Try and think of a password that someone else would not guess easily. Do not leave the password written on a piece of paper stuck to your computer or on a noticeboard near your computer. This is an invitation for unauthorised people to access your work or documents. In case you forget what your password is, it’s a good idea to write down your password in a private place that only you know about.

Backing up information

Your organisation will have a policy on backing up information. You may be required to back up your own information. Alternatively, there may be someone in the organisation whose role is to regularly back up information on all computers. Most organisations would be backing up at least once a week and often it will be more regular, depending on the nature of work undertaken in the agency.

Intranet

When there are a number of people in an office or in a number of offices/locations an internal system to access and manage files is often adopted. This is called an Intranet. An Intranet is an internal website that stores organisational information. It is usually only accessed by staff of the organisation that have a password to the system. An organisation’s Intranet may contain guidelines, policies and procedures, forms, minutes of meetings and newsletters.

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Databases

A great way to store information that once was put in bulky directories is to use a database such as Excel or Access. Databases are flexible and can be updated easily. There is often one person in the organisation responsible for updating the database.

Databases might include information about:

local community organisations

members of community organisations

clients

Confidentiality is very important with regards to databases.

Folder heading systemYou need to have a system of naming files within folders so you can find your files. Like a filing cabinet you need to have drawers, and folders within the drawers, that are clearly labelled so you can find information. When there are multiple users of computers and files it is essential that the file names are clear and ordered. Some organisations use a letter and numbering system to store their electronic files and documents while others have a series of clearly identified words.

This would be a good time to attempt Activity 7 before moving on with the remainder of this reading.

Certificate IV in Disabilities: CHCICS402A LO 8544 Reading 13© NSW DET 2009

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References

WebsitesAccommodation Policy and Development Directorate —Client risk Policy and procedures, Final 1.0 NSW Department of Ageing, Disability and Home Care March 2008 http://www.dadhc.nsw.gov.au/NR/rdonlyres/C21BABCF-6001-400F-9D38-E4042FAD6281/3863/ClientRisk_Policy_Procedures.pdf

Active places—http://www.activeplaces.com.au/show_links.php

American Speech-Language-Hearing Association (1997). Guidelines for meeting the communication needs of persons with severe disabilities. http://www.asha.org/docs/html/GL1992-00201.html

Aspire, Communicating in Aged Care http://www.aspirelearningresources.com.au/pdf/CHCCOM2B_Sample.pdf

Beth Reutter Corporate Etiquette Consultant University of Illinois at Urbana-Champaign Dept of Food Science & Human Nutrition Hospitality Management Program Business Etiquette How Savvy Are You? http://www.expertvillage.com/video-series/9417_business-basic-etiquette.htm—videos on appropriate introduction

Autism Queensland Support Group Newsletters— http://www.autismqld.com.au/services/Help_supportGroupNewsletters.html

Centre for Developmental Disability Studies, for the NSW Department of Ageing, Disability and Home Care Client Participation in the Individual Planning Process 35

The Robert Wood Johnson Foundation Self-Determination Initiative: Final Impact Assessment Report—http://www.hsri.org/docs/767aRWJFinalImpactAssessmentReport.pdf

Community Living and Respite Services Disability Standards, http://www.clrs.org.au/about-subs/disstandards.html

DADHC – Standards in Action http://www.dadhc.nsw.gov.au/NR/rdonlyres/0D67293C-E601-4816-8E24-DCED089C866F/668/Standardsinaction_93582882.pdf

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Department of Sport and Recreation—The Department of Sport and Recreation is the lead agency responsible for the implementation of government policy and initiatives in sport and recreation. http://www.dsr.nsw.gov.au/

DuPraw, M & Axner, M 2002, Working on Common Cross-cultural Communication Challenges. http://www.jyu.fi/mclinic/cis/cross-cultural.html

Easy English version of the Commonwealth Disability Standards—http://www.facsia.gov.au/sa/disability/pubs/employers/Pages/DisabilityServicesStandardseasyEnglish.aspx

Foundation for People with Learning Disabilities, (2000). Choice for people with learning disabilities and high support needs. http://www.learningdisabilities.org.uk/publications/?esctl526505_entryid5=22282&char=C

HACC Standards— http://www.health.gov.au/internet/main/publishing.nsf/Content/hacc-pub_isd_nssi.htm

Indiana Family and Social Services Administration (2004). People with Disabilities—Person Centered Planning Guidelines. http://www.in.gov/fssa/servicedisabl/bqis/pcpguidelines.html

Joint Guarantee of Service (JGOS). http://www.housing.nsw.gov.au/NR/rdonlyres/FEC00408-610B-4B14-A5B8-143A35715728/0/JGOSreferenceguide_Sec7.pdf

Jones, J. (2001). Communication. BILD Factsheets no. 005. British Institute of Learning Disabilities, UK. http://www.bild.org.uk/pdfs/05faqs/communication.pdf

Meeting room booking form example, http://www.fireindustrytraining.com.au/web_images/Room%20Booking%20Form.pdf

National Dissemination Center for Children with Disabilities, (2004). Fact Sheet 10: severe and/or multiple disabilities. www.nichcy.org/pubs/factshe/fs10txt.htm

The Big Tree: Person Centred Planning—http://web.thebigtree.org/personcentredplanning/page.php?pid=389

Riding for the Disabled Association of Australia, http://www.rda.org.au/\

Sanderson, H. (2000). Person centred planning: key features and approaches. http://www.helensandersonassociates.co.uk/PDFs/PCP%20Key%20Features%20and%20Styles.pdf

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Self Advocacy, Sydney— http://sasinc.com.au/

Smull, M.W., Sanderson, H., & Burke Harrison, S. (1996). Reviewing essential lifestyle plans: criteria for best plans. Annapolis, MD: Support Development Associates. http://www.nwtdt.com/Archive/pcp/bestplans.html

Ten Items For A 10-Year Plan for Disability Services Service. http://www.nds.org.au/nsw/newsitems/2006/ACROD10yearItems.pdf

The Housing Connection, http://www.thc.org.au/what.html

Wehmeyer, M. (2002). Promoting the self-determination of students with severe disabilities. http://www.ericdigests.org/2003-4/severe-disabilities.html

Other resourcesAllen, W. T. (2002). It’s my choice. Allen, Shea & Associates, California USA.

Anderson, M.D., Sherman, J.A., Sheldon, J.B., & McAdam, D. (1997). Picture activity schedules and engagement of adults with mental retardation in a group home. Research in Developmental Disabilities, 18 (4) 231-250.

Barber, M. (1994). Contingency awareness: putting research into the classroom. In J. Coupe-O'Kane and B. Smith (eds) Taking control: enabling people with learning difficulties. London : D. Fulton Publishers. 49-59.

Beukelman, D., & Mirenda, P. (1998). Augmentative and alternative communication: management of severe communication disorders in children and adults, Second Edition. Baltimore, MD: Paul H. Brookes Publishing Co.

Billinglsey, F.F. (1984). Where are the generalized outcomes? (an examination of instructional objectives). Journal of the Association for Severe Handicaps. 9 (3) 186-192.

Campbell, P. H., Strickland, B., & La Forme, C. (1992). Enhancing parent participation in the individualized service plan. Topics in Early Childhood Special Education, 11 (4), 112-124.

Carnaby, S. (1997). A comparative approach to evaluating individual planning for people with learning disabilities: challenging the assumptions. Disability & Society, 12 (3), 381-394.

Carr, J. E., Nicolson, A. C., & Higbee, T. (2000). Evaluation of a brief multiple-stimulus preference assessment in a naturalistic context. Journal of Applied Behaviour Analysis, 33 (3), 353-357.

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Chambers, D. (2002). The effect of training on student-directed planning practices. AFCEC Online Journal. Special issue, October.

Ciulla Timmons, J., & Whitney-Thomas, J. (1998), The most important member: Facilitating the focus person’s participation in person centred planning. Institute for Community Inclusion Research to Practice, 4 (1).

Community Services Appeals Tribunal and Community Services Commission. Reasons for Decisions - I’d like that in writing ... thanks! (brochure), 1997.

Community Services Appeals Tribunal and Community Services Commission, Getting it Write: Information for community service providers on the requirements to give service users reasons for certain decisions (brochure), 1997.

Coupe O'Kane, J., & Goldbart, J. (1998). Communication before speech: development and assessment (2nd ed.). London: Daniel Fulton Publishers.

Cross, A., Sherwin, J., Collins, P., Funnell, B. & Rodgers, M. (Eds.). (1999). Gathering of Wisdom. CRU Publications, Brisbane.

Cummins, R.A., Baxter, C., Hudson, A.H., & Jaurnig, R. (1996). A model system for the evaluation of individual program plans. Journal of Intellectual and Developmental Disability, 21 (1), 59-70.

Cummins, R.A., Jaurnig, R., Baxter, C., & Hudson, A.H. (1996). A model system for the construction and evaluation of individual program plans. Australia and New Zealand Journal of Developmental Disabilities, 19 (3) 221-231.

Dagnan, D. J., & Sturmey, P. (1994). Validation of technical criteria for setting IPP goals for persons with developmental disabilities in residential settings. Behavioral Interventions, 9 (1), 67-73.

Dalton, B. A. (2002). Unleashing the power of person-cented planning & continuous quality improvement in North Carolina’s MH/DD/SAS system. University of North Carolina.

De Kock, U., Saxby, H., Felce, D., Thomas, M., & Jenkins, J. (1988). Individual planning for adults with severe or profound mental handicaps in a community-based service. Mental Handicap, 16, 152-155.

DePaepe, P., Reichle, J., Doss, S., Light Shriner, C., & Cameron, J. (1994). A preliminary evaluation of written individualized habilitation objectives and their correspondence with direct implementation. Journal of the Association for Severe Handicaps. 19 (2), 94-104.

Department of Health (2001). Planning With People: Towards Person Centred Approaches. Guidance for Implementation groups. London: Department of Health.

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Department of Speech-Language Pathology (2003). AAC STRATEGIES 1 Non-symbolic Communication for Beginning Communicators SLP 1521S Augmentative and Alternative Communication, Faculty of Medicine: University of Toronto.

Downing, J. (1988). Active versus passive programming: A critique of IEP objectives for students with the most severe disabilities. JASH, 13, (3) 197-201.

Emerson, E., & Stancliffe, R. (2004). Planning and action: Comments on Mansell & Beadle-Brown. Journal of Applied Research in Intellectual Disabilities, 17 (1), 23-26.

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