Dos of Documentation
Who should do the charting?
The person is providing care or observed event.
What is a Comprehensive Behaviour Support Plan (CBSP)?
A written plan which documents process and results with recording of the process with the participant.
Aims to provide ecological changes, positive programming, focused support and reactive strategies
Report suspicion or evidence of abuse outside of plus to _______
Who will notify _______
Supervisor or Coordinator
General Manager
What is neglect
Failure to provide necessary supports that may result in harm or loss appropriate to participants demographic.
Including but not limited to: food, clothing, shelter, etc.
May or may not be intentional
Chart the facts, not...
your opinions
It is important to include the ______ & ______ on your entry.
Date & Time
Understand the participant's potential for violence and/or abusive behaviour
Demonstrate they can implement CBSP
Sign off on training
What should you do if you do not feel safe?
Remove yourself from the situation
What is sexual abuse?
Any form of exploitative sexual behaviour or unwanted sexual touch. Eg. harassment, sexual assault, etc.
Don't leave empty spaces, instead...
When should charting take place?
As soon as possible.
When will investigations take place?
An internal investigation will be conducted following all incidents of violent and or abusive behaviour where warranted
Evidence of Physical or Psychological Abuse
Any outward signs of bodily injury
Repeated occurrences of agitation or depression, abnormal emotion displayed
If the alleged perpetrator is a staff, board member or other person associated with the organization?
Alleged perpetrator will be made known of allegations, and removed from worksite. And be informed an investigation is taking place.
If police are involved, police will inform perpetrator
Don't name a second client as this violates that client's confidentiality, instead refer to the second client as:
"roommate"
"another client"
"peer"
How do you continue documentation that continues onto the next page?
Sign bottom, and place date/time at the top of page and include "continued from Previous page"
OR
Draw a line through the blanks at the end of the page and start on next page.
A file will be opened on each incident and will contain:
Written and signed statements by staff members and witness(es)
Outcome of review
Investigation Committee report and all other pertinent information
Define Violence
Attempted, threatened, and actual action that causes or could cause injury
Includes threats that could be thought to cause the worker injury
When and who are are you obligated to report?
Immediately
Supervisor or in their absence the General Manager
Don't alter a clients record, this is a criminal offense, this can include:
Don't add information at a later date without indicating that you did so.
Don't date the entry so that it appears to have been written at an earlier time.
Don't add inaccurate information.
Don't destroy records.
What three things do we need to consider to chart completely, concisely and accurately?
Write clear direct sentences
Use simple and precise words
It's okay to use "I"
Post incident actions to be taken for the affected staff member:
Medical treatment as required arranged by GM
Debriefing and support, and reassurance the staff is still in a safe work environment
Opportunity for post incident counselling
Option to contact police will be supported
No loss of pay or benefits with treatment/counselling/training program
Even without policy you have the right to
Seek or exercise legal rights through RCMP, Saskatchewan Human Rights Commission, or Occupational Health and Safety Division
Ensure confidentiality of all information related to an allegation of abuse by:
Treating all information obtained as confidential and limited to those directly involved
Plus Industries Inc. will inform third-party representatives/advocates that information is confidential
Don't white out or erase what has been written, instead ______