Language, please!
These documents can be seen by other staff, parents, possibly students, insurance companies, probation officers, judges, the courts or litigators.
What are EXTERNAL documents? (accessible to others outside the CCT system). Staff should always be mindful that what is written in notes that can be seen by others and should edit/communicate accordingly. These may include group, individual and monthly/ weekly progress notes.
If staff deems that UA/Breathalyzer testing is not warranted but suspicions still remain, this information should be noted here.
What is the Communication Log?
Media calls
Who is the Executive Director?
This is assigned when a student engages in relapse behavior.
What is a Chain Analysis?
Staff shall not purchase items for CCT without proper authorization from these individuals.
Who are their direct supervisor or the Executive Director?
Initials or "a peer".
How do you refer to other students in documentation about a specific student?
"Never use another student’s name in a student’s note. Please use, initials, “a peer,” “a male peer,” etc."
Separate the student from others and call On-Call.
What is what to do when a student is intoxicated or in active relapse?
Vehicle problems
Who is the Facilities Manager and Operations Director?
What is an Incident Report?
Never copy and/or release any portion of a student’s file without the consent of these individuals.
Who are the Clinical or Executive Director and a signed release from the student?
With phrases such as: the student reported..., stated..., said...
How do you report what a student said in documentation?
Do not document that a student “felt” or “believed” something even if the student says, “I feel angry.” Rather, document that the student “reported,” “stated,” “said,” that he felt angry. For example, “John feels that he is being mistreated by the group – WRONG.”
“John stated that he feels mistreated by the group – RIGHT.” In point of fact legally, you can never know what a person feels, thinks or believes – only what they SAY they feel, think, or believe.
These 4 Staff should notified if a staff member discovers or learns of a previous relapse.
Who are: an administrator, Recovery Coordinator, Therapist and Case Manager?
Time off or late arrival
Who is your direct supervisor?
This form (in the student’s own words) relates Successes and Accomplishments in the past month, Challenges and Obstacles to progress in the past month, and Actions to Improve in the next month.
What is a Student Treatment Review Form?
If the staff person plans to take one to two days off, a _________ notice to supervisor is expected. If the staff person plans to take one week or more off, _________ notice is expected.
What are 2 weeks and 1 month?
“John became red-faced and raised his voice as he told the group to ‘f*&% off.’" is an example of...
How to objectively document foul language and student behaviors?
Never use foul language even if you are quoting the student. Use the first and last letter and symbols in between.
This is a team decision and must involve an administrator!
What is required for dismissal from the program in the event of multiple relapses?
Questions about Implementing a consequence, house rule or other milieu management concern.
Who is the Program Director?
Expected documentation by this staff include:
Communication log entry of significant events of their shift.
Notation on medication sheet for meds dispensed.
Notation on Daily Record for students’ participation and timeliness on activities.
Incident Report for incidents involving students during shift.
What are Residential Coach Documentation responsibilities?
Because we are a treatment team, information about student’s progress must be shared among staff so that a holistic view of the student’s progress can be maintained and so that appropriate treatment is given.
Why Staff should never promise a student that the staff member will keep information confidential from other staff?
When filling out this form, DO NOT critique the program, policies or procedures or make suggestions for change on this form and AVOID making clinical assessments of student functioning in this report.
What is an INCIDENT REPORT?
Do not attempt to handle this type of student behavior by yourself, even if you feel confident in your skill level. Call the Clinical Director or On-Call.
What do I do if a student self-harms?
A visit to the hospital happens.
Who are the student's parents and On-call?
Clinical documentation (In BestNotes) is mandatory and essential to what we do for these reasons.
(2 out of 4 reasons minimum to win this response)
What is:
Remember: when we implement this, we must exhaust other interventions first, present it in a supportive manner, and indicated that we are still hoping and supporting a successful outcome.
What is a Contract with a student?