One thing we advise new DSP’s to do is to keep a small notebook on their person. To write down answers to questions; to write down phone numbers and other info needed for the job.
Seasoned DSPs can also make use of a small notebook. They’re cheap, can be bought almost anywhere and come in so handy for direct care professionals. A great resource, the little notebook.
I have one…pocket size that fits nicely in my jean pocket. What do I do with it? A lot. When a client needs vital signs, I have paper to record the results. When a weight is needed; when a height is needed; when intake and output need to be recorded- these little pads come in real handy. When behavior data is to be collected the notebook provides an efficient place to write it all down.
• At the top of the page I write the date…day, month, year and shift I am working.
• I record the times I clock in and out so if there is a discrepancy in my pay I can go back and check.
• I record what program/unit I’m working at, and the initials of the staff working with me.
• I record my assigned clients’ first names. No need for more info; names are enough.
• Any falls, incidents or other incidents are recorded in my notebook as well…the vital stats are documented. Who. What. When. Where. Witnesses.
Many DSPs and CNA’s use an assignment sheet to record all this info…and that’s fine. But I like to keep a personal record of these things. It can help you keep a clear record of your daily work and one never knows when this information can become necessary to defend one’s actions. Some DSP’s prefer to write notes about their workday at home, away from prying eyes and nosy bosses. No matter where you do this, it’s pretty important to DO IT.You don’t have to tell ANYONE.
There is controversy about this. Some will say this is a HIPAA violation. It is not when full names are not written, when detailed notation is made about identifying health information. No one else is going to look out for you when it comes right down to decision about whether you provided substandard care or were involved in an incident that led to detrimental results.
The legal environment in today’s group home agencies demand we keep clear records of the care we give. Most nursing/group home management can be trusted to not alter records, but not all. Aides & DSPs can and have gotten into seriously trouble over issues and incidents that were not properly documented; flow sheets have been “corrected” to suit the best looking picture. Since aides/DSP are the lowest people in the chain of command, it is way too easy to blame us for problems, issues, accidents and the like. Let’s face it: We’re easy targets to blame for higher managements lack of direction/policy/oversight and training.
Who hasn’t been called at home, by the boss or HR Dept., demanding to know details about some incident that occurred last week? And who among us has a truly clear recollection of the events? If we had written down all the details, it would certainly help us during this call. Or, who has been involved in an incident that a state agency is tasked with investigating? The best defense you can have are your personal notes.
A little notebook can keep a lot of vital information. I wouldn’t go around telling everyone I have one though…management often doesn’t take well to such things. We have to be extremely careful to respect HIPAA rules, but it is within our right to keep notes about our workday. I strongly advise all direct care workers to do this.