report writing and documentation 1 (1)
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Professionalism
There are several reports and items ofdocumentation that need to be completed bytreatment parents to track the youths progress,document information needed for licensing andmedicaid requirements
Caseworkers and other consumers are more willingto place youth and see you as a professionaltreatment provider when these items are:
1. On Time 2. Complete and Accurate 3. Good Quality of Work
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Reports
Reports that are required of treatmentfoster parents are: Monthly SDS ( Skills Development Summary)
Timeliness due by the 5th of every month
Complete and Accurate all information filled incompletely with appropriate signatures. Quality of Work- report should be written with
detailed and specific information in the appropriateplaces. Request feedback monthly to make surethese are meeting medicaid requirements and
information useful in tracking youths progress andthe planned interventions to be used the followingmonth.
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Reports: Monthly SDS Goal # __ - to be taken directly from treatment plan in the
same order even if goal is discontinued or resolved.Example: Goal #1 Increase Acceptance of Authority
Presenting Problem- why the youth needs treatmentExample: (Youth) has a tendency to argue with adults when told no and refusesto be compliant when given rules or directions.
Progress- Identify strengths, approximations, shaping orchaining of behaviors that are improving in frequency,duration, or intensity. Identify behaviors that there is
more improvement needed and how that is going to beattained. Example: ( Youth) has shown improvement this month by completing tasks, both
daily and spontaneous without arguing.He/She is able to recite the steps to following instructions, accepting criticism,accepting no and disagreeing appropriately. ( Youth) still argues, stomps feetor cries when told no or given a consequence, requiring prompting to controlemotions and frequently earning additional consequences. We will continue torole play controlling emotions daily and provide additional reinforcement for the
times he/she is able to do this on their own. Continued Need for SDS the skills the youth still needs tolearn to be able to resolve this goal area.
Example: (Youth) continues to need to learn to say okay, controlhis/her emotions, and avoid arguing on a daily basis
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Insert Monthly SDS Worksheet inManual
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Incident Reports
Incident reports are required by licensing, DCFS and JJSas well as other consumers to document incidences such asserious youth behaviors, ( I.E. running away, suspension,aggression, property damage etc.), injuries to youth, reportsor allegations of abuse, and other items specified on theform. All subsystems should trigger an incident report.
Timeliness Abuse, injuries must be completed within 24hours. All others must be done within 72 hours. Complete and Accurate All information must be filled out and
accurate. Quality of Work The incident should be written behaviorally
specific complete with addresses of location, times of events,
names of individuals involved. The documentation should notinclude judgment calls, slang, or derogatory terms other thenitems directly quoted.
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Insert Incident Report
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List of Documentation Fire Drill Logs Medication Logs Youth Accounts and Receipts CHEC/ Dental/ Mental Health
Morning Report/ contacts and activities Family Meetings Documentation of Daily SDS on motivation
system tool ( point cards, etc.)
Other Tracking Sheets: School notes, Jobnotes, and Home Visit Notes
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Documentation will be
checked by Consultants andCaseworkers. Meet with
your consultant and go over
Each item in the Reportsand Documentation
Notebooks.
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Paperwork and Documentation Timeline
Yearly CHEC, licensing paperwork, consumers Six months
- Dental, Insurance papers, first consumer Quarterly
- Staffings, Quarterly Reports, YOQs
Monthly- Youth Accounts/Receipts, Monthly SDS, Morning Report andContacts, Med logs turned in, fire drills
Weekly- Contact with consumers, weekly sheets
Daily- Point cards, School Notes, documentation of medications,documentation of daily contact, activities
As Needed- Incidence Reports, Subsystem Worksheets
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Turned into Consultant
Point Cards School Notes or Job Notes Home Notes Monthly SDS Youth Account/ Receipts Incident Reports Subsystem Worksheets Morning Reports CHECS/Dentals/ Therapy
Copies of Report Cards, Court information andStaffing information and other items you wouldlike kept in Youth File at office
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Return to Office
Billing Statement
Other
* Everything else should be kept in youth file athome and out of home folder or in documentationnotebooks.
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Due by the 5th:
To Consultant:- Monthly SDS
- Point Cards or SDS
YOQs Copy of Youth accounts and receipts
Copy of Youth medication logs
To Diane:
- Billing Statement
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This training presentation is available for download at:
www.utahparenting.org
2007 Utah Youth Village.