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Clinical Documentation

What is clinical documentation?  Clinical documentation is any sort of paperwork that is produced to reflect some aspect of a person’s support needs and preferences, what they want to achieve through services, and/or the progress they are making towards achieving those outcomes.

Some of the most important documents that we use include:
ISP – Individual Support Plan. Also called the Person-Centered Plan (PCP,) this document reflects where a person is, where s/he wants to be, and what services are being put in place to support him/her in getting there.
RSNA – Risk/Support Needs Assessment. This document reflects some of the risks the person may face to his/her health and safety and how those risks are being addressed.  This information may be included in a different format other than an RSNA, but it is always included in clinical documentation.
STG – Short Term Goals. A person’s short term (or short range) goals are based on the Long-Range Goals that appear in the ISP. They are the goals that we work on with the person as an agency. The STG document will spell out how it is that staff are to run and to assess progress for the goals. These details are spelled out so that the goals can be run and assessed the same way no matter who is working with the person on a given day.
EGGs. The EGGs (electronically-generated goal sheets) are what the agency uses to reflect the progress that a person is making on the short-term goals. EGGs are completed using Therap.
QPR – Quarterly Progress Report. A QPR is completed by the clinical department each quarter for people who receive services. The QPR reflects progress that the person made on their goals during the quarter as well as any significant events or changes that occurred that are considered to be significant to the person’s progress with services.

In addition to the documents listed above, a person’s clinical file may also have psychological assessments, medical records, and other documents produced by medical or other professionals. Our agency also completes behavior data sheets for some folks, and we may track bathroom visits or other aspects of daily living for others. There are other documents that we and other team members create as well.  All together these documents make up the person's clinical record.

Where does clinical documentation come from?  The ISP and RSNA are created by the person’s care coordinator with input from the whole treatment team, of which MSS is just one part. The STG, goal sheet, and QPR are produced within the agency. The Clinical team is responsible for creating and monitoring them.

Where is clinical documentation kept?  The Administrative Director is responsible for keeping all clinical records electronically. Paper documents that the agency uses must be kept secure and under double lock.  This applies to any documentation that is produced by SEI, AFL, and other residential service providers.  Some documentation is kept on Therap as well for your reference.  The Clinical Team may keep paper versions of some of the documentation for reference.  All current documentation that is relevant to the work you do is available to you for the person or people you support through Therap.


What’s on the clinical documentation?  Different information is required to be on different pieces of documentation. What goes on the different documents to some degree is dictated by the Records Management and Documentation Manual put out by the North Carolina Department of Health and Human Services.  In other words, we have to follow the rules made by the State, and the paperwork we produce is reviewed by others on a regular basis.  In a nutshell, though, clinical documentation includes information about the person and their services.

What happens to old clinical documentation?  We are required to hold on to all clinical documentation for a long, long time. Even if MSS were to go out of business, we would be required to make sure that all of the documentation we receive and produce is stored and accessible long after the doors close. This applies to documentation for all of the services that MSS provides.  Sometimes we get requests for documentation that is over four years old and, if we can’t locate everything, we have to pay back some of what was billed that long ago.  aperP documentation is kept securely in boxes and safely in storage.  Electronic documentation is kept within the systems in which it is produced, and some of it is kept electronically by the Administrative Director.

Why is clinical documentation important?  The services that we provide are funded by taxpayers such as yourself. We are accountable to those taxpayers for how we spend the money. Also, the people who choose us for their services deserve to have a record of their progress with us and of what services were provided. The information can help the person to make decisions about further supports and services and can help to promote continuity across providers and across time.  We don't make the rules about clinical documentation - The Center for Medicare and Medicaid Services and the State of North Carolina make the rules.  We follow them as best we can to insure the best possible outcome for the folks we support.

Anything else I need to know?  Your role in understanding and producing clinical documentation is a crucial part of your job no matter what your role is in the agency. If you are providing direct support, your paperwork requirements have been streamlined as much as possible so that you can spend the majority of your time interacting with the people we support.

There is a saying in this industry that if it isn’t written down, it never happened. You need to keep that in mind when you are completing the clinical documentation that you are required to complete. You won’t always be around to explain what you did, what you observed, or what you recommend based on the work that you do. Your input is valuable, and you need to take credit for the effort that you put into your work. Make sure that the documentation that you produce reflects your professionalism. The Clinical Team, which includes your clinical supervisor, can help you to reach higher levels of professionalism in all that you do, including in your documentation. Use them as a resource to increase your understanding and performance in this area.

Clinical documentation must be truthful, accurate, and thorough. It also must be kept confidential. Think about your own medical records. You don’t want there to be things on there that aren’t true, and you don’t want anything to be left out. You also want to make sure that any person who has access to your records has permission to have that information. Any time you have questions about how to prevent or report Falsification of Documentation, how to maintain confidentiality, or how to report breeches of confidentiality, please ask until you get the answers that you need to be sure you are in compliance in these areas. We are committed to providing the same respect for the folks we support as we expect to receive from people who keep important records that concern us.

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