documentation and office work

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documentation of services documentation and office work maxkamov dilshodbek aluzswlu, 06-22 at the end of this session, the participants will be able to: define person centered documentation explain documentation “do’s” and “don’ts” explain the purpose of progress notes define an isp explain the purpose of a medical report demonstrate the ability to document progress notes and a medical report objectives agencies must follow certain guidelines in gathering material for their records: keep information that is only relevant inform individual from whom it collects information by what authority the agency is allowed to gather info purposes for which info will be used person centered documentation sign your name and title write down date and shift time use good grammar and write in complete sentences write neatly and legibly; may want to print use initials when referring to other people receiving services write down facts and support it with details related to …

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progress notes also known as isp contains important information about the consumer is the consumer’s history, a list of things to do, and a plan for making future hopes and dreams a reality is unique to the individual individual service plan is goal oriented is structured for success is supported by the team and the staff that work with the consumer is outcome oriented so that each team member knows where, why, how and what they are expected to do and when they should do it individual service plan is reinforced; goals are worked on and carried to the consumer’s various environments (home, school or community) so that everyone knows what is expected wherever the consumer may be provides the supports to make the difficult possible planning for the consumer’s independence requires knowledge of that person’s history and how he/she adapts to different circumstances individual service plan progress notes person:_______________ …

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ntil after 2 am. he woke up at 6 am and said he had a headache. he took some tylenol and went back to bed. he was asleep when i left. progress notes person:___john smith__ month: _june year: _2004 error nj gourmente to theee thesote., soduife we wneee say it. he lefjks thereee reallhad. sally got up late this morning. i think she is lazy. jessica rabbit 8/10/ 04 7:20 pm betty arrived home from work at 5:15 pm. she said “i’m hungry”, we made a sandwich. debbie smith 8/10/ 04 9:00 am lsojgkjdkljklj. sam paid all the bills tonight. after supper. joseph blow 8/10/ 04 1:20 pm gloria’s mother came to see her today. when gloria got back she took her medication and made dinner. tom brady 8/10/ 04 6:15 am when i got here, first shift did not do anything, so betty didn’t get her bath. l brown …

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brushed his teeth. you remind him to comb his hair and shave. he put on his favorite blue shirt from the laundry basket and you point out that shirt is dirty and support him to choose the clean purple shirt. you tell him he can wash his clothes later and wear the blue shirt when it is clean. you load the dishwasher and vacuum the living room. you remind john to clean the bathroom and he cleans the shower, tub and toilet with only one reminder. john wants to go grocery shopping so you both make a grocery list and go to the store. he says he does not want milk even though he is out of milk. he buys apples and bananas and baked chips. he wanted some ketchup so you and john compared prices. john does not like chek drinks even they cost less than pepsi. he likes …

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ional’s name and office information current medications and dosages allergies reason (s) for visit medical reports purpose name:__________________________________________________ date of birth: ________ address: ______________________________________________________________ phone #: _________________________ ss #: ________________________ insurance type: _____________________ insurance #: __________________ emergency contact: _____________________________________________________ address: ________________________ phone #: _____________________________ medical professional: __________________________ title: _____________________________ address: _________________________________________________________________________ current medications: _______________________________________________________________ allergies: ________________________________________________________________________ reason for visit: __________________________________________________________________ signature of medical professional: _________________________________ date: ___________ sample medical report form progress notes are legal documents always maintain confidentiality summary thanks for attention image1.jpeg /docprops/thumbnail.jpeg

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documentation of services documentation and office work maxkamov dilshodbek aluzswlu, 06-22 at the end of this session, the participants will be able to: define person centered documentation explain documentation “do’s” and “don’ts” explain the purpose of progress notes define an isp explain the purpose of a medical report demonstrate the ability to document progress notes and a medical report objectives agencies must follow certain guidelines in gathering material for their records: keep information that is only relevant inform individual from whom it collects information by what authority the agency is allowed to gather info purposes for which info will be used person centered documentation sign your name and title write down date and shift time use good grammar and write …

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