Iowa Family Services

3319 109th St.

Urbandale, IA. 50322



Phone: 515-270-0093

Fax: 515-270-4939

Documentation Hints for Providers


 

Figuring out what, when, and how to document properly can be confusing! You may have worked for a different agency with different expectations, certain things may seem important for some consumers and not for others, and figuring out how to document events clearly and concisely can be tricky! We understand all of that and wanted to offer some assistance.

 

First...

Respite notes are very important and are Medicaid documentation. They are subject to audits and reviews by the state at any time. There is a standard format for notes that will be provided for each consumer you work with.

 

*If you work with a consumer who has a behavior that the family, case manager, or provider would like to track, we can add that to the notes format as a reminder for you to document that information. For example, if you work with a consumer who wets the bed frequently, we can add a section on bedwetting to the notes format. To have that added to the format, have the family or case manager contact us to do so.

 

If you are running low on notes, just call us and we can get you more ASAP!  

 


The basics...


All of the information and sections on each note should be filled out. If there is no information for that section, that should be indicated. For example, in the section that reads "(Consumer) slept during the following times," rather than leaving it blank you might put a slash or write none to indicate that the child did not sleep while you provided services, if that were the case. DO NOT FORGET TO SELECT INDIVIDUAL OR GROUP HOURS AT THE TOP OF THE FORM. 


Notes should be completed at the end of each service. Notes can be written as you change activities throughout the day or at the end of the service, but they must be completed by the end of that shift so that the consumer's guardian can review your documentation and sign off. Trying to go back and remember all of your activities and the consumer's behaviors can make for inaccurate documentation.


Notes need to be signed. Each note should have a guardian's signature AND your signature. Because this is a Medicaid document, both signatures are needed to verify the accuracy of the note.


There should be a new note for every day. If you are doing an overnight, there will need to be a note for each day. Notes will stop at midnight and then a new note will start.


Be thorough in your documentation. Notes need to paint a picture of all the activities and things that happened while you provided services. Time spent on activities, changes in activities, and behaviors should all be included.


Include specific locations. If you are going places in the community, be specific about where by including street names, cross sections, and addresses as appropriate.


Each note needs to say "I/provider supervised." The only goal of respite is to provide care and supervision as the child's guardian(s) would. Notes should reflect that you did just that!


Include interventions and consumer's response to interventions. For example, if the consumer is refusing to shower for the day, you might write "I asked Jon to shower and he refused to do so. I explained that if he did not shower, we would not be able to go to the bowling alley. Jon waited in silence for five minutes and then went upstairs and showered."


Use blue or black ink. Pencil fades and colored pens can be difficult to read or copy.


We need the original copy of each of your notes. Faxed or scanned notes aren't considered original documents.

               

If your notes are missing necessary information, we will have to send them back to you to complete and add details to. We cannot pay you for those hours until that information is completed and the note is returned. It's much easier to look them over to make sure they are complete and detailed before you send them in!


Examples...

Instead of this...

Write this...

Went to his house. Played soccer, ate dinner, went to bed.

Provider went to John's home and supervised him while he played soccer in the backyard with his brother.   After playing soccer for about an hour, John was tired and came inside for dinner. John finished his dinner, got ready for bed, and went to bed at 8:15. John got ready and went to bed without needing any prompts or re-directions.  

(Complete sentences and details are important! )

 

Betty was being so silly.  Guess what she did? She put the socks on her hands and put on a show! Betty pretended she was a fairy and I pretended to be a goblin. Betty laughed and laughed and laughed and we had such a good time playing together. Betty is such a sweet girl.

Provider and Betty played with sock puppets. Betty was very imaginative and silly while playing. She was in a great mood and really seemed to enjoy the activity.

(Facts about the activity rather than opinions. Clear and to the point!)

 

Timothy ate: very well. he must have been hungry.

Timothy ate: 2 pieces of pizza, applesauce, popcorn, and an ice cream cone.

(We're only looking for what was actually consumed in this section.)

 

Liz was angry with Bobby Smith for taking her turn on the Wii and started yelling at her.

Liz was angry with her peer for taking her turn on the Wii and started yelling at her.

(Don't list the names of other consumers or family members in documentation.)

 

Behaviors and Interventions: Scott would not listen. He was very stubborn all day and received consequences.

Behaviors and Interventions: Scott struggled to follow provider's directions to complete tasks throughout the day (brush his teeth, use the restroom, help clean up after lunch, etc).   Provider reminded Scott several times of the expectations and asked him nicely to complete the tasks. When Scott was still unable to complete the tasks after many prompts, Provider told Scott he would not be able to play outside on the swings until he was able to finish the tasks. Scott was upset about this, but then was able to complete the tasks.

(Details about what the issue was, what the intervention was, what the consequence was, and what the outcome was are very helpful!)

 


Documentation Due Dates and Pay Periods

Dates of Services

Notes Due By

Pay Checks Mailed

1st-15th of the month

19th of the same month

26th of the same month

16th-31st of the month

4th of the next month

11th of the next month