Essential Components of Documentation for Paraprofessionals

OBJECTIVES
At the completion of this training, participants will
– Understand the importance of documentation – Know how to set up and maintain records – Understand the connection between accurate record keeping and the Individualized Treatment Planning process – Understand what information needs to be in progress notes – Learn how to accurately set up and maintain a medication administration record – Understand that records are confidential – Know how to conduct a quantitative review of a record – Know how to conduct a qualitative review of a record – Be able to track consumer issues through a record

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The challenge for all service providers is to understand the “whys” of documentation while also understanding the “hows”. If we are able to understand the “whys”, the mundane tasks of everyday documentation and record keeping become something that is part of the whole instead of the dreaded work we face every day.

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Let’s Begin With A Little Chat about Program Quality
You may notice that this training seems to be mostly about paper, not people.

That doesn’t mean we don’t like people
In fact some of our best friends are…. well, people.

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And it’s not that we think “Good Paper Equates to Good Program”
In fact, we’ve seen some very lousy programs that have really “good paper”. We call that, “doing the wrong thing, very, very well”.

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But the thing is………..
In looking back, it’s been extremely rare that we have found really good services with really poor documentation.

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Let’s face it………..
If we are going to keep up with all that we do to provide quality service … We’re going to have to write it down

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So, here’s how you write it down!…………

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Why such a big deal about