Professional Documentation - Robert Wood Johnson Medical ...

Professional Documentation

Name: ____________________________________________ Mentoring Time: ________

Mentoring Discussion

Please select 5 of the following topics to discuss with your mentor.

Discussion Topic ? Explain documentation in the context of your work setting.

Describe examples of both formal and informal documentation and how you utilize both.

Check as Completed

? Describe why documentation is important. What are some examples from your own experience that help demonstrate why documentation is important.

? What are some things you do in your work to clearly demonstrate how to follow basic rules of documentation? Why this is important for accurate and legal documentation entries?

? Describe the difference between objective and subjective documentation? What questions are answered by each?

? Explain the concept of confidentiality and demonstrate how you protect the confidential information of those you support, including not only written, printed, and electronic documentation but also verbal communication.

? Describe how to complete authorization to release information forms correctly. How would you explain to the person being supported what information is being requested and why, so he or she is able to understand the request and give informed consent?

? Confidentially discuss some of the Individual Support Plan goals for a person she or he supports. Share why Individual Support Plans are important and how they affect services and supports to the person and how information about progress is documented.

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Discussion Topic

Check as Completed

? Discuss how you use the staff communication log is used at the

workplace, explain why this communication tool is important as part

of the workplace's daily operation and demonstrate how best to

make log entries.

? Describe what information is needed on an accident or incident report form, explain why it is important to complete these forms accurately and with factual, objective information, and can compete an agency accident and incident report form accurately and completely.

Please sign in the spaces below.

This Direct Support Professional has successfully completed the coursework and displayed competency on the job as it relates to Professional Documentation.

_________________________________ _________________________________ _________________________________

Direct Support Professional

Mentor

Supervisor/Agency Approval

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Portfolio Activities/Work Samples (Choose 1)

1. Create a work sample of documentation examples in different formats she or he uses on the job. These can be actual or fictional examples. Write a reflective essay on the reasons documentation is important and how it impacts the supports being provided to individuals served by the agency. The essay should include either real life examples based on the individuals he or she supports or fictional examples. The examples should contain clear explanations of how the documentation is important to the individual's support and services. The work sample should include a summary paragraph explaining how these examples are important and beneficial to the people being supported.

2. Gather a group of work samples using actual documentation entries or fictional entries. The learner should select at least 7 of the rules covered in this lesson and on each of the work samples she or he will highlight a part of the entry and explains how it applies to the rule. A summary statement should be included that explains what she or he has learned by completing this exercise and how it will inform daily practice moving forward.

3. Complete a reflective essay on how you protect the confidential information of those she or he supports and why this is important to daily practice. The essay should include specific examples of how confidential and private information is protected. Further, the essay should outline any applicable state laws, rules, and regulations he or she must follow; employer confidential information policies and procedures; and any federal regulations like HIPAA. The essay should conclude with a summary statement outlining what has been learned by completing this exercise and how the learner will change his or her future documentation practices because of it.

4. Submit a work sample containing communications in the staff communication log for a time period of one week. Write a list of topics covered during this period and summarize how this information impacted those being supported or not. Summarize how this information impacted the staff as well. The work sample will include a summary statement about the role the staff communication log plays in daily practice.

5. DSP Choice

Develop a work sample that demonstrates your hands-on work in community human services. Include in your portfolio any materials you have used or developed, any relevant video or pictures you may have taken to show your accomplishments, a brief written summary of the activity, and a personal reflection. The work sample you create must accomplish the following:

? Focus on what you've learned in the Documentation Module found in the College of Direct Support;

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? Be completed on-the-job to improve the life/lives of people you support and/or increase your professionalism;

? Demonstrate mastery of one (1) of the competency areas outlined by NADSP (See Appendix A); and

? Demonstrate Best Practice.

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