Tuesday, September 9, 2014

New Documentation Instructions

We are currently reviewing documentation and making changes. If you have not already received new documentation for your clients, you will soon.  

First, the number of goals has been shortened and the criteria to meet the objective has been stated in more detail. 

Secondly, the number rating system to indicate performance on the objective has been replaced with the I, V, P system.  Each goal that you work on during the day will be assigned a letter:

I= independently (client completed the objective without any prompts or assistance at all)

V=verbal prompts (client completed the objective with verbal prompts given)

P=Physical prompts (client required physical prompts to complete the objective. These can range from pointing him in the right direction, pointing to the spot to begin the activity or leading client to the place needed up to actually physically assisting him to complete the task, up to and including hand-over hand assistance)

The third thing is not new, but is being restated now.  For every goal marked as worked on as now indicated by an I, V, or P, there MUST be a corresponding note pertaining to that objective.  This is where you can indicate what assistance was needed and how you assisted with the activity.  If verbal prompts were indicated, for example, did you prompt once and the task was then completed by the client? Or were multiple prompts required?  The narrative note portion MUST MATCH the top portion where a letter was assigned.  Do not mark, for example, that you worked on community activities, yet say nothing about going anywhere in your notes.

If you have any questions, please call the case manager assigned to your client, 501-847-5901.