CDS-E: Professional Documentation Practices
Lesson Descriptions and Learning Objectives
CDS-E: Professional Documentation Practices
This is a list of lessons found in this course with their description and learning objectives:
Lesson 1: CDS-E: The Purpose and Meaning of Documentation in Direct Support Work
Lesson Description:
Documentation is a critical part of direct support work. In this lesson you will learn what documentation is and why it is important to direct support work. You will learn that documentation's purpose, whether in paper form or electronic, is to communicate information.
Learning Objective
After completing this lesson, you will be able to:
- Define documentation in direct support work and explain why documentation is important
Lesson 2: CDS-E: Reasons for Documentation
Lesson Description:
In this lesson you will learn more about the seven common reasons for documentation. You will begin to explore how documentation can help you provide better supports. You will also learn why it is important to those being supported.
Learning Objective
After completing this lesson, you will be able to:
- Identify and explain seven common reasons for documentation in direct support work
Lesson 3: CDS-E: The Basic Rules of Documentation
Lesson Description:
This lesson covers some of the basic rules for documentation. You will learn about rules covering any type of documentation. This includes formal and informal. It also covers both handwritten and electronic documentation.
Learning Objective
After completing this lesson, you will be able to:
- Identify and demonstrate how to follow the basic rules used in completing effective and legal documentation
Lesson 4: CDS-E: Documentation and the Direct Support Professional
Lesson Description:
This lesson will provide some helpful guidelines for writing effective and useful documentation entries. You will learn to write documentation entries that are clear and concise. You will learn the difference between objective and subjective entries. This will help provide valuable information to other support team members and help improve the quality of supports for the individuals being supported.
Learning Objective
After completing this lesson, you will be able to:
- Identify, explain and demonstrate how to record information in your documentation that is accurate, clear, and concise documentation
Lesson 5: CDS-E: Protecting Confidentiality
Lesson Description:
In your work as a direct support professional you will be reviewing a lot of documentation about the person you support. You will need this information to do a good job. Documentation will have private information about the person. This lesson will help you understand your role in protecting the person's private information. You will learn about confidentiality and why this is important to your everyday practice.
Learning Objective
After completing this lesson, you will be able to:
- Define confidentiality, explain why it is important in documentation, and demonstrate in daily practice ways you will protect the confidentiality of the people you support
Lesson 6: CDS-E: Rights to Privacy
Lesson Description:
This lesson explains a person's rights to privacy. It also identifies some common substitute decision makers. These are people who are legally authorized to make decisions for the individual receiving supports. They would also have access to a person's confidential information.
Learning Objective
After completing this lesson, you will be able to:
- Explain a person's right to privacy and explain how this affects who can have access to a person's private and confidential information
Lesson 7: CDS-E: Release of Information Forms
Lesson Description:
This lesson will help you understand what information is needed in order to secure a proper release of information form from a person being supported or their legal surrogate decision maker. You will learn what information should be included on an authorization form. You will also learn about appropriate ways to request information from the person or their legal surrogate decision maker.
Learning Objective
After completing this lesson, you will be able to:
- Describe methods for ensuring people have given appropriate consent and information is released correctly
Lesson 8: CDS-E: Individual Support Plans, Progress, and Personal Goals
Lesson Description:
This lesson is about Individual Support Plans. It also covers personal goals and progress reporting. These plans are used to guide the supports and services a person receives. The plans also help individuals reach individual goals, dreams, and preferences. You will use these in everyday practice.
Learning Objective
After completing this lesson, you will be able to:
- Explain what Individual Support Plans are and how they are used to support the individual with disability make progress and achieve personal goals, dreams and preferences and then show how these are used in everyday practice
Lesson 9: CDS-E: Medical and Health Related Documentation
Lesson Description:
Good health is important in everyone's life. As a direct support professional, you need to encourage good health for the people you support. One way to do this is through the completion of medical documentation. In this lesson you will be introduced to medical and health related documentation forms.
Learning Objective
After completing this lesson, you will be able to:
- Identify the three medical and health related documentation types, explain why these are important and demonstrate how to correctly document information on each type
Lesson 10: CDS-E: Staff Communication Logs
Lesson Description:
Communication on the job is important. You need to be able to communicate with other staff across different shifts and different work days. This helps work places run smoothly. A staff communication log is at the hub of daily staff communications. This lesson is about staff communication logs. The lesson explains what staff communications logs are and how they are used to communicate important information.
Learning Objective
After completing this lesson, you will be able to:
- Describe the purpose of a staff communication log, explain how it is used as a communication tool in the work place and demonstrate appropriate use of the log on the job
Lesson 11: CDS-E: Incident and Accident Documentation
Lesson Description:
Accidents and incidents do happen on the job. This lesson will review accident and incident documentation. You will learn what information is needed on an accident and incidents report form.
Learning Objective
After completing this lesson, you will be able to:
- Describe the five key pieces of information you need to report on for every accident or incident, explain why this information is important and demonstrate how to fully and accurately complete an accident or incident form