Ronnie says, “I’ve learned how important event notes are, especially for the following reasons.”
Documents progress towards meeting individual’s needs and desires
Notes are legal documents and are subject to open records requests
Ensures continuity of service for individual
Improves accountability between the GSSW and individual
Acknowledges GSSW for the quality of work completed
Allows oversight of the services being performed
Ronnie says, “As we discussed earlier, the following are expectations for documentation.”
Effective documentation:
Establishes accountability and evidence of services provided.
Provides an accurate, timely, objective account of an individual’s situation, services, plan of care progress or the lack of, interventions, challenges, health, and other relevant information.
Is valuable at the time of intervention and for years in the future.
What is the purpose of effective documentation?
Helps to assure continuity of care.
Helps the service team remember events.
Serves to tell a story and helps identify patterns of behavior.
Provides a record of information used by the GSSW and other service providers in team meetings and court hearings.