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"An Introduction to Basic Documentation"

by Michael True, M.Ed

This comprehensive overview of documentation practices has been created for program administrators and individuals seeking a basic knowledge of these issues. Documentation is the cornerstone of most community-based programs and services. Providing your direct care and training providers with the keys to this process, promises quality services for your consumers. Packets can be used within a group or given privately to an individual needing to enhance current knowledge and skills. In this packet I have added a documents checklist. This can be used seperately or during group training to record inservices done on actual data collection systems you are using in-house.

Training kits include questions for discussion, a pre and post test, and test key.

Topic Headings Include: Why Do We Use Documentation?, Consumer Response, Types of Documentation, Keeping Good Records, Common Documentation Problems, Observation, Reporting Incidents, Data Collection Sheets or Forms, and How Documentation is Used. CD now includes a Spanish Translation!

Sample Text:

Objectives:

At the end of this unit participants will be able to:

1.Understand the principals behind using accurate documentation techniques

2. Identify various forms of documentation used in program administration.

3. Know and use successful documentation practices

4. Recognize and avoid common documentation mistakes.

5. Know and use the basic principals of good observation.

6. Know and use documentation principals associated with Special Incidents

"Why Do We Use Documentation?

As a caregiver it is very important that you understand the value of providing documentation. Documentation gives us, and those who may be working with us, the most current and accurate information available. One of your responsibilities will be to observe, report, and record changes in a person's condition and her or his response or lack of response to the care and treatment provided."

"Types of Documentation

As a care provider you will be expected to provide documentation at some point. This can be as simple as writing down telephone messages or as complex as making behavioral observations. In each of these cases it is important that the information that you provide be accurate and well written.

When you are providing documentation for a program or service that receives funding from government sources, it is especially important that you follow certain rules. These rules are made to insure that you are providing a program or service that meets the standards that are legally required. If errors are frequently made, your program or service may be subject to fines or actions that could result in the termination of funding altogether. This may also be the case if important documentation is missing from required files."

"Observation

Most documentation requires you to make observations. Making good observations requires some practice. First, it is important to understand, for the purposes of documentation, what is meant by the word observation.

Observation is recognizing and noticing the facts surrounding an individual's activities and personal condition. It means taking note of, or paying attention to, what is happening around them and yourself.

You must be alert to obvious visible changes, as well as, to subtle changes in an individual's physical condition, mental attitude, or behavior patterns. Observation is not merely looking; it is planned, careful, and focused.

Observation involves using your senses.

WHAT DO YOU SEE? WHAT DO YOU HEAR? WHAT DO YOU SMELL? WHAT DO YOU FEEL?"

Pre and Post Test (sample questions)

True/False - write T or F in blank space

_____1. Subjective comments are useful in daily documentation.

_____2. Recording data should occur as soon as possible after the activity being observed occurs.

Test also includes "matching" questions for a total of 15.

The complete packet consists of 11 published pages of text, a one page competency test, (pre-post), and test key, (8 1/2" x 11" pages pages when printed from files.)

All text files are formatted in Microsoft Word and will be sent by way of email unless otherwise agreed upon. This training packet consists of 7 files and is currently priced at $104.95. These files are available for UNLIMITED** use in making your own packets in-house and can be used as often as you like within your program without further cost to you!

To purchase: Use my Paypay or Venmo accounts – username: mstrue1@hotmail.com (Michael True) - Provide Training Packet Title: "An Introduction to Basic Documentation" and include recipient's email address.

For personal assistance or for any questions you may have, contact me:

Michael True C/O TruEnergy Enterprises

At: mstrue1@hotmail.com - or phone: 504-906-9343

(ALL PACKET FILES WILL BE MAILED WITHIN 48 HOURS OF RECEIPT OF PAYMENT

**Use of the "An Introduction to Basic Documentation"© 2002-2024 packet is subject to all Copyright Laws. Possession of the Authorized Microsoft Word files constitutes permission to copy the training materials for use in only the program(s) or service(s) to which the buyer is associated at the time of purchase. Transfer of data for use in other programs or services without prior consent of the author is strictly prohibited. Michael S. True, Author and TruEnergy Enterprises - All Rights Reserved.

If this product, (7 Microsoft Word files) is defective as a result of corrupted files, it may be replaced for up to 30 days from the date of purchase without further charge to the purchaser. Simply contact me and a replacement set will be sent upon verification of the original purchase.

"All text files are formatted in Microsoft Word and will be sent by way of email unless otherwise agreed upon. This training packet consists of 7 files and is currently priced at $89.95. These files are available for UNLIMITED** use in making your own packets in-house and can be used as often as you like within your program without further cost to you!

For personal assistance or for any questions you may have, contact me:

Michael True C/O TruEnergy Enterprises

At: mstrue1@hotmail.com - or phone: 504-906-9343

(ALL PACKET FILES WILL BE MAILED WITHIN 48 HOURS OF RECEIPT OF PAYMENT

"An Introduction to Basic Documentation" is also available as part of the special promo below...

Choosing of our 6-Pac (6 Individual Staff Development Packets), or MultiPac (12 Individual Staff Development Packets), CAN SAVE YOU UP TO 60% off individual packet prices! Each of the twelve topics are covered masterfully in self-contained MSWORD files that include Questions for Discussion, tests, and Administrative Supplements. Two economic ways to enhance your staff development program today!

Twelve Topics for the New Direct Care Provider collection

or the

Six Topics for the New Direct Care Provider collection

(Click on Title Above for More Details)

To make payment: use my

Paypal or Venmo accounts

mstrue1@hotmail.com = my username...