Report Writing and Documentation 1 (1)

8/3/2019 Report Writing and Documentation 1 (1)

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Report WritingReport WritingAnd DocumentationAnd DocumentationReport WritingReport WritingAnd DocumentationAnd Documentation


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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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Report WritingReport WritingAnd DocumentationAnd Documentation

Report WritingReport WritingAnd DocumentationAnd Documentation

This training presentation is available for download at:

www.utahparenting.org

2007 Utah Youth Village.

Documents

Report Writing and Documentation 1 (1)