Sunday, September 13, 2015

Email Provides a Simple Documentation Method

In the world of ICF/IID settings documentation is often critical not only to remind others of what has been completed or set in motion, but also to prove something happened.  There's a good chance that most people reading this post has at least some level of familiarity with documentation.  We usually call it "Q Notes" or "QIDP Notes".  It could also be that documentation is maintained in the form of an Interim staffing or a "Mini-Staffing".  Naturally we all know that documentation is also present in the IPP, Data, Annual CFA, Assessments, Referrals, and Reviews.  Q Notes are often meant to cover small items that do not occur during the annual staffing, may not be a big enough event for an IPP or staffing, and may only be needed to prove you did address something.

How many times have you found yourself in front of a surveyor who asked, "So, what did you do about this situation when you were notified?"  You stand there for a moment thinking to yourself, "Yeah, right, that was six months, two weeks, a day, and four hours ago right before I went to lunch and had a cheeseburger....Yes, I told everyone at 11 am, that we would....." Yeah, right.  It's more likely that that you stood there with a "Deer in the headlight" look on your face and said, "Yes, we addressed that and talked about it as a team."  You know the next question coming: "So, do you have any notes about that?"  This is when panic sets in.  You run through your mind quickly and think, "Did I do a Q Note, have a Interim, anything?"  You quickly tell the surveyor you have to go check.  Now you're in the chart digging and looking for an event that happened six months ago that you may or may not have completed any documentation on at that time.  Worse, you may be at your desk digging through stacks of paper and trying to find that one sticky note where you placed the documentation.    Worse yet, you may be thinking that the event occurred when you were not even at the your note may be on your home desk or anywhere in your car for that matter.

Now, let's face the facts....most likely you did not do the note.  You may not have been at the office, you talked on the phone, made a decision, moved forward and forgot about it.  But what if it is something that you really need some sort of documentation for?  Let's say it's something that you know, beyond any doubt, that a surveyor is very likely to ask you about or it may come up.  This is where you need to consider modern documentation and how simple it can be.

Most QIDPs have email now.  If you do not, get an account and change your calendar from 1995.  You can open a Gmail account for free and it will hold all your emails - up to a gigabyte or so- at no charge.  You can also search your email by keywords, email addresses, etc.  Once you have your email account, put it on your smart phone, tablet, or simply your computer.  Now use it.  The next time you have a situation that may need to be documented, send yourself a note or send it to a member of the IDTeam or even your Director.  You may want to let them know in advance that you're going send it so it is not confusing.

Let's consider this example for a moment.  Johnny lives at ICF -A.  Johnny had a bad day and broke a window.  The IDTeam has already approved Johnny paying for the window.  You get a call on Sunday afternoon telling you about the event.  You tell staff that Johnny will need to know he is paying for the window and you talk with Johnny.  Johnny agrees (he is calm now) and says he will pay.  You are at the park with your family - no notepad, no computer, just your trusty cell phone.  You send the following email to your manager:

Manager - Johnny broke a window today about 2:00pm.  We talked about it on the phone and he is calm now.  He knows he needs to pay for this and has agreed to pay for the window.  Please implement this Monday morning as soon as possible.  I would like a report indicating the status on this by Wednesday.  If you need more time, please let me know and have staff reminded to follow current behavior plans.

The above note has covered what happened, the intervention you did, and the fact that Johnny understands he is to pay for the window.  You also have the opportunity to send the email not only to your manager, but you might send it to your supervisor, other members of Johnny's team, his parent or guardian, and even if possible to Johnny's own email account.  The note also has valuable information.  It will be date stamped for Sunday afternoon and will have a time on it as well.  It will also show a list of people you notified.    It is now part of your email record.

Fast forward by four months, and the financial auditor is reviewing Johnny's records.  She sees where Johnny signed a check and paid for something to "XWY Glass" in the amount of $250.  She comes to you and says, "I see the consent and that Johnny agreed.  What is this about though?"  You can easily give her Johnny's approved behavior plan that shows that he has to pay for broken items.  You can then do a search in your email and pull the email by date, Johnny's name, or possibly even the keywords "broken glass".  You show the email as to where you addressed this initially to coincide with the behavior plan.   The surveyor then returns to the financial audit satisfied.  You have your plan, your documentation, and your manager followed your directives and obtained correct consents.
As a further precaution, should you feel compelled, you can "CC" yourself the email as well.  Once you get it, you can print it out and put it with all the time stamps and date stamps in Johnny's chart.   You could also print out a copy of the sent email if you would prefer.   The email will then essentially serve as a "Q Note".  This is always a good idea in case you get that outstanding job offer and decide to leave Johnny's organization for that much higher paying QIDP job!

The bottom line is that documentation is needed, but don't hesitate to utilize the email factor for documentation.  It can save you time and provide a digital, date, and time stamped record of the event.  You can then have it on your email server or even have a printed hard copy on file.   It's a simple documentation method that is often overlooked in the ICF/IID field and other fields as well.