1. All documents or
entries in the client record should minimally include the client's name, case
number, date, and writer's signature and
2. All direct
service employees and supervisors will have internet access from home in order
to facilitate the documentation of services to client records.
3. All documents or
entries in the client record should be legible, completed, dated, and signed by
the person making the entry, written in ink or typed, and properly corrected as
corrected means that errors are voided by crossing out the incorrect entry with
one line, writing "void" next to the crossed out entry, and initialing and
dating the correction.
5. White-Out shall
not be used to correct errors in client records.
documentation included in the client's case record helps serve as a
basis for the planning, implementation, and continuity of the service program,
and as a means of communication among the professionals who may contribute to
the client's services.
7. It will be the
responsibility of the Clinical Supervisor to ensure that appropriate records
are maintained on each client receiving services from his/her service providers
8. All employees,
contractees, student interns, and consultants shall document all service
provided to clients in a timely, accurate, and orderly fashion. "Timely" for
this purpose means is within 48 hours of service. This documentation will
include progress towards service plan goals as well as other interactions that
may be pertinent to the service needs of the client.