SA

Study Notes on SBA, Documentation, Client Support, and IT Considerations

Confidentiality and Ethics in Documentation

  • Context of Discussion: Discussion about sending documents to individuals without encryption (referring to Gabe's case).
    • Key Points:
    • Sending documents without encryption may raise ethical concerns.
    • In this case, sending the document to Gabe's mother is acceptable as she is the authorized recipient, and there’s no risk of violating confidentiality by sending it directly to her.

SBA Report (Skill Building Activity)

  • Understanding SBA Reports: Emphasis on how SBA reports should capture total sessions and percentages accurately.
    • Primary Objective: To maintain consistency in reporting data based on how the statements or reports are structured.
    • For example, maintaining total session goals clearly without transitioning to percentages when the original reports were documented in totals.
    • Narrative of Experience:
    • Previous reporting involved creating plans without the capability to generate percentage reports. Prior experiences made transitions to reporting complex without proper tooling.
    • The goal mentioned was to document a total of 30 sessions based on expectations, yet found discrepancies in recorded sessions (i.e., 16 sessions documented instead).
  • Reflections on Documentation:
    • Example noted: The need to adjust expectations based on actual recorded sessions versus the total expected. Recommendations to reduce total sessions might be necessary for accuracy (i.e., lowering from 30 to 15 sessions).
    • Complexity in reporting arises when there’s a need for accountability, assessment of missed targets, and systematic updates to goals.

SBA and Quarterly Reviews

  • ** Quarterly Review Process:**
    • Reflection on how quarterly reviews should be straightforward and numbers-based: either goals are achieved, unmet, or require adjustments. The process can become layered if discrepancies in goals exist.
    • Potential Updates Required in SBA Documentation: Recommendations to simplify and adjust for future SBA documentation to be concise while still reflecting real progress.

Importance of IT Considerations

  • Update Process Concerns:
    • Warning against losing important documentation during updates (PCRs could be lost during revisions if not managed correctly).
    • Care to consult IT before making changes to avoid data loss is essential.

Shared Outcomes and Implementation

  • Shared Outcomes Overview:
    • Emphasis on writing clear and effective documentation using present tense (e.g., articulated as “Nephi identifies” versus “Nephi will identify”).
    • Need for specificity in outlining the individuals' interests and supports, alongside providing two to three concrete examples for clarity.
  • Effective Support Documentation:
    • Encourage documenting methods of assistance in detail for DSPs to understand how to engage effectively with clients.

Client Relationships and Support Structuring

  • Communication Purposes:
    • Importance of verbal reminders and education regarding personal care tasks (e.g. showering, medication adherence).
    • Potential statements to encourage self-care while maintaining a clear boundary about medication administration and transportation considerations.

ISPs and Documentation Sharing

  • Individual Support Plans (ISP):
    • Utilization of details from the ISP gives clarity on the individual's historical context and preferences.
    • Acknowledgment of existing protocols within the ISP, but must remain flexible to allow changes that arise from the client's evolving needs.

Skills Training and Developing Supports

  • Focus Areas for Skills Training:
    • The need for ongoing training to support skill building, emphasizing independence in personal care tasks for clients.
    • Engagement in social skills and addressing interpersonal interactions should be documented through a collaborative and descriptive approach.

Review of Plans and Documentation Methodology

  • Plan for Support (PFS) Entry:
    • Each section must be addressed in a flowing narrative format for continuity and clarity. This includes potential and identified risks, routine supports, and behavioral expectations within documentation.
    • Use clear labeling on risks that outlines preventative strategies and documentation strategies, ensuring a reliable narrative for potential and identified risks based on ISP data for uniformity in records.

Closing Thoughts and Scheduling Follow-ups

  • Future Meetings Scheduled:

  • Provision for future meetings to discuss ongoing assessments and enhancements for skill building activities and client interactions are laid out.

  • Encourage maintaining communication among team members, sharing insights, and opening discussions about individual development and upcoming duties.

  • General Note: Respectful consideration of updates and revisions to plans will contribute to the overall wellness and effective service delivery for the individuals being supported.