Documentation: What’s your role?

  1. Keep accurate documentation. Never "fudge" on required documentation. If you don't understand how to document something, ask your supervisor.
  2. Be sure to sign and date all entries you make when you make them, whether in staff notes, learning logs or checklists. Some agencies use Electronic Health Record or “EHR” systems of documentation, so you could be using a computer to document your work.
  3. Learn to write objectively. Write down what you see, hear, or otherwise observe. Do not include your conclusions or opinions in documentation unless you say that it is YOUR opinion. For example if you have an idea or a hunch about why an individual might act a certain way, make sure you write that it is your opinion.
  4. Know the Plans for Supports for people you support. You are responsible for providing services as outlined in the plan and recording what you do, what you learned and things that are important to know for supporting the individual. When you know what both you and the person are supposed to be doing, your documentation will reflect this knowledge.
  5. Know why you are documenting. If you are unsure or question why a piece of documentation is needed, ask your supervisor to explain. You will be more likely to complete better documentation if you understand the reason for the requirement.
  6. Include ideas you have in your documentation. As you get to know an individual, share with your team or your supervisor your ideas for changes or improvements to the Plan for Supports, such as ways to make the plan better match the person’s strengths, interests and support needs.
  7. Provide accurate, clear, and detailed information. Remember that all documentation is subject to review by licensing and funding agencies and, in some cases, could be subpoenaed for an appeal hearing or other legal action.
  8. Never use white-out or erase ink. Mark through errors with a single line, initial and when making late corrections date any changes made to the record.
  9. Record information about the person’s likes and dislikes, as well as other input he/she shares in appropriate places in the record.