CDS-E: Professional Documentation Practices
Related Competencies
CDS-E: Professional Documentation Practices
College of Direct Support (CDS)
The College of Direct Support (CDS) is a competency based training and development tool. These competency sets are nationally validated and/or come from expert consensus. The foundation of competencies makes lessons and courses easier to use in a coordinated way. They can be selected to develop a person’s overall competence. They can be used to create a meaningful development plan. These lists provide you with the competency sets that reinforce the CDS content. They indicate the specific competencies covered by this lesson or course.
NADSP Competency Areas
The following competency areas and skill statements are used by the National Alliance on Direct Support Professionals (NADSP). The NADSP set is based on the Community Support Skills Standards (HSRI, 1996). The CSSS are a nationally validated set of competencies for DSPs. The ones listed below are only part of the whole set. They are the knowledge and skills a learner must be able to demonstrate at a basic level of competence having completed the content. See the full set of NADSP competencies and to learn more about the NADSP.
Area 2: Communication
The Direct Support Professional should be knowledgeable about the range of effective communication strategies and skills necessary to establish a collaborative relationship with the participant.
Skill Statements
- The competent DSP uses effective, sensitive communication skills to build rapport and channels of communication by recognizing and adapting to the range of participant communication styles.
- The skilled DSP learns and uses terminology appropriately, explaining as necessary to ensure participant understanding.
Area 12: Documentation
The Direct Support Professional is aware of the requirements for documentation in his or her organization and is able to manage these requirements efficiently.
Skill Statements
- The competent DSP maintains accurate records, collecting, compiling and evaluating data, and submitting records to appropriate sources in a timely fashion.
- The competent DSP maintains standards of confidentiality and ethical practice.
- The competent DSP learns and remains current with appropriate documentation systems, setting priorities and developing a system to manage documentation.
Area 13: Building and Maintaining Friendships and Relationships
Support the participant in the development of friendships and other relationships.
Skill Statements
- The competent DSP documents community activities and events.
The Centers for Medicare and Medicaid Services (CMS)- Direct Support Workforce Core Competencies.
The CMS core competencies for the Direct Service Workforce (DSW) were part of an initiative to improve access to high quality LTSS for all populations. The competencies are designed to improve worker quality. These competencies are designed to inform direct support service delivery and promote best practices in community-based LTSS. They are also a core foundation to career development. Only some of the competencies are listed here. These are the ones a learner should be able to demonstrate basic competence in once completing the content. Read the full set of CMS-DSW competencies.
Area 1: Communication
The DSW builds trust and productive relationships with people s/he supports, co-workers and others through respectful and clear verbal and written communication.
Skill Statements:
The Direct Service Worker:
- Uses positive and respectful verbal, non-verbal and written communication a way that can be understood by the individual, and actively listens and responds to him or her in a respectful, caring manner.
Area 2: Person-Centered Practices
The DSW uses person-centered practices, assisting individuals to make choices and plan goals, and provides services to help individuals achieve their goals.
Skill Statements:
The Direct Service Worker:
- Completes and submits documentation of services on time.
Area 3: Evaluation and Observation
The DSW closely monitors an individual’s physical and emotional health, gathers information about the individual, and communicates observations to guide services.
Skill Statements:
The Direct Service Worker:
- Collects data about individual goals and satisfaction with services.
Area 4: Crisis Prevention and Intervention
The DSW identifies risk and behaviors that that can lead to a crisis, and uses effective strategies to prevent or intervene in the crisis in collaboration with others.
Skill Statements:
The Direct Service Worker:
- Reports incidents according to rules.
- Sees own potential role within a conflict or crisis and changes behavior to minimize conflict.
Area 6: Professionalism and Ethics
The DSW works in a professional and ethical manner, maintaining confidentiality and respecting individual and family rights.
Skill Statements:
The Direct Service Worker:
- Follows relevant laws, regulations and is guided by ethical standards when doing work tasks.
- Maintains confidentiality in all spoken and written communication, and follows in the rules in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Area 12: Education, Training and Self-Development
The DSW obtains and maintains necessary certifications, and seeks opportunities to improve their skills and work practices through further education and training.
Skill Statements:
The Direct Service Worker:
- Learns and stays current with technology used for documentation, communication and other work activities.
NADD An Association for Persons with Developmental Disabilities and Mental Health Needs DSP Competency Standards
Supporting people with co-occurring intellectual disabilities and mental illnesses well takes special skill, knowledge, and effort. The NADD competency standards were to define critical areas of skill that people need to do this well. There are several levels of competencies developed by national experts in this area. The ones listed below are only part of the set for direct support professionals. They are the ones that a learner should be able to demonstrate at a basic level of competence having completed the course. Read the full set of NADD competencies and related certification and accreditation efforts.
Competency Standard 1: Assessment and Observation
The qualified direct support professional (DSP) is competent in the area of “assessment and observation” as it relates to individuals with Intellectual or Developmental Disabilities and Mental Illness (IDD/MI).
Benchmark 1D: Documentation and Communication Related to Assessment and Observation
The qualified DSP demonstrates effective skills in documentation and communication of assessment information and observations to others. The DSP maintains ethical and legal standards of confidentiality.
Benchmark 1D Performance Indicators
In the area of “documentation and communication,” the qualified DSP:
- Documents observations accurately and objectively in clear, measurable terms.
- Observes and records behavior related to medication management clearly and consistently.
- Reports and documents risks to individual health and safety promptly.
- Communicates and documents information in a professional and culturally-sensitive manner.
- Discriminates between essential and non-essential information and reports only and all essential information when documenting or communicating.
Competency Standard 2: Behavior Support
The qualified direct support professional (DSP) is competent in the area of “behavior support” as it relates to individuals with Intellectual or Developmental Disabilities and Mental Illness (IDD/MI).
Benchmark 2C: Responds to Challenging Behavior
The qualified DSP can successfully interrupt or prevent use of challenging behavior. He/she responds to challenging behavior in a skillful, respectful, and professional manner. The qualified DSP uses information from the whole team to develop and assess strategies.
Benchmark 2C Performance Indicators
In the area of “responding to challenging behavior,” the qualified DSP:
- Documents any incidents of challenging behavior in accordance with existing plans and policies. Follows documentation protocol for special incident reporting and contacts appropriate team member(s) or supervisor(s).
Competency Standard 3: Crisis Prevention and Intervention
The qualified direct support professional (DSP) is competent in the area of “crisis prevention and intervention” as it relates to individuals with Intellectual or Developmental Disabilities and Mental Illness (IDD/MI).
Benchmark 3C: Documentation and Communication of Crisis Situations
The qualified DSP recognizes that effective and complete documentation of crisis events is useful. It will guide future decisions regarding prevention and response in crisis. He/she follows all employer documentation guidelines as well as the state documentation requirements. The qualified DSP is familiar with and skilled at following each individual’s treatment plan. He/she communicates with the treatment team as indicated. The qualified DSP understands his/her unique position to observe and document individual behavior. This will support the treatment team in understanding behavioral antecedents and possible positive reinforcements.
Benchmark 3C Performance Indicators
In the area of “documentation and communication of crisis situations,” the qualified DSP:
- Documents and communicates observations regarding the coping skills identified in treatment and behavior support plans in accordance with agency policy and state guidelines.
- Identifies and documents mental health symptoms to be monitored according to the individual’s treatment plan.
- Recognizes and documents changes in behavior, including responses to specific interventions.
- Documents and reports events of crisis incidents accurately and in a timely manner, in accordance with agency policy and state guidelines.
Competency Standard 4: Health and Wellness
The qualified direct support professional (DSP) is competent in the area of “health and wellness” as it relates to individuals with Intellectual or Developmental Disabilities and Mental Illness (IDD/MI).
Benchmark 4E: Documentation and Communication Related to Health and Wellness
The qualified DSP recognizes that for people with IDD/MI behavioral symptoms are often a key component to the diagnosis and treatment of health disorders. The DSP takes time to maintain accurate and complete documentation in accordance with agency/ organizational guidelines. He/she organizes and communicates this information in useful ways. The DSP teaches skills to assist individuals in monitoring their symptoms and maintaining personal records.
Benchmark 4E Performance Indicators
In the area of “documentation and communication,” the qualified DSP:
- Recognizes critical information to document and share with others.
- Follows the documentation requirements and guidelines of their state and agency/organization and records important information as it relates to individuals.
- Maintains complete, objective and accurate documentation regarding current needs of each individual.
- Helps maintain a medical history that includes medications and treatments that have been ineffective or aversive.