1. NADD competency-based DSP certification program-
COMPETENCY STANDARD #1 ASSESSMENT AND OBSERVATION
This course is part of the NADD competency based DSP (direct support professional) certification program. Your observations count toward the larger picture of an individual’s health, psychological state, mental health, and overall well being. You, THE DSP, can tell when a person with IDD that you work with is sad, happy, or sick just through your knowledge of that person, your daily assessment of that person, and your keen observation that the person is different today than yesterday.
Authors: Tony Thomas, Macdonald Metzger, Melissa Cheplic

2. NADD-DSP Assessment and Observation
Assessment and Observation is one area of competency in the NADD DSP Certification program. Below is the full list of all the areas in the DSP competency set.
Competency Standard 1: Assessment and Observation
Competency Standard 2: Behavior Support
Competency Standard 3: Crisis Prevention and Intervention
Competency Standard 4: Health and Wellness
Competency Standard 5: Community Collaboration and Teamwork
PLUS…Application and commitment to the Code of Ethics
Presenter- mention the NADSP code of ethics and refer to it. For more history you can go to:
Whenever possible, provide opportunities to review the code of ethics as it applies to behavior support. When we are supporting people, there may be more than one intervention that seems feasible, what is the most person-centered, best practice, ethical option for this person?

3. Educational Objectives
By the end of this webinar, participants will have received training on the first NADD DSP Competency Standard: Assessment and Observation and be able to:
Define Formal and informal assessments
Describe the use of assessment and observation tools
Demonstrate proficiency in observing and recording behavior
Demonstrate use of helpful documentation practices and communication related to assessment and observation
Think about the various roles you have as a DSP and how those roles align with each of these learner objectives. As you go through this webinar please reflect on how you will apply what you learn in this course in your work with people you support.
This course is meant to help a person in the role of the DSP supporting people with Intellectual or Developmental Disabilities and Co-occurring Mental Health Conditions to understand key aspects of their role in the area of Assessment and Observation. You will learn why assessment and observation are important. You will recognize common assessments that may be useful when supporting people with these conditions. You will be educated on core observation skills and be reminded of critical aspects of informal and formal assessments (changes in behavior/ability, etc.).
This course will also review crucial aspects of communication and documentation related to this competency area but not touch on these areas with great length

4. Benchmark 1A: Knowledge of Assessment and Observation Process
The qualified DSP is knowledgeable regarding specific methods of assessment. The DSP is aware of potential cultural bias in formal assessment and works with others to ensure accuracy. The DSP uses results of assessments in planning, implementing, and evaluating services and outcomes.
The qualified DSP demonstrates knowledge of the specific assessments and observations of individuals served, including assessments from other professionals.
He or she describes when, how, and with whom to share assessment information with others, assures confidentiality of assessment and observation information, and is aware of agency’s confidentiality policies about sharing information. There is no more important statement we will make today in this webinar than this one.

5. Benchmark 1A: Knowledge of Assessment and Observation Process
Assessment is the process of collecting information about a person’s strengths and needs. It can be used in decision-making. It can also be used to overcome potential barriers to quality services and supports in a person’s environment.
Some examples of what assessment can help with:
identifying physical or mental health concerns;
identifying environmental triggers to behaviors;
identifying how well medications or therapies are working;
identifying areas where a person may need additional skills and supports;
and much more.
Accurate assessment and organization of information may make all the difference to someone with IDD/MI.
Accurate assessment supports good health. It helps identify the function of the behavior. It ensures important aspects of care are not overlooked. For individuals with IDD/MI, comprehensive assessment or targeted assessments may be extremely important. These individuals may have serious barriers to communication. Someone who is troubled or challenged and is out of control and has no speech will rely on your assessment to help them.

6. Why Is Assessment Important?
A person-centered assessment helps understand the person as a part of the community and in the context of their strengths, preference, and expectations.
Assessments help identify barriers to people living an ordinary life where they can be supported.
Accurate assessments help identify opportunities to understand strengths, goals, and support in achieving them.
The results of an effective assessment can help identify barriers to services and life choices that enable people to live self fulfilling lives. An assessment is beneficial in identifying opportunities to understand the person’s strengths and goals and in supporting in them in achieving outcomes.
Without good assessment of needs, preferences, hopes, goals, strengths, etc. people may not have a very high quality of life.
Assessment is used to gather evidence to understanding current problems, to evaluate progress and outcomes, and to understand the effectiveness of interventions and programs. Full or complete assessment looks at different areas in the person’s life that includes behavior, but includes also many areas of their wellbeing.
The DSP assesses individuals in many areas. These include health, safety, and functional life skills. They can also include behavior, emotional state, response to medication, and signs of crisis.

7. Formal and Informal Assessments
Are standardized and validated through research
Have specific administration and scoring procedures
Often require credentialing or training to administer
Informal assessment:
Includes observations, interviews, documents/record reviews
Is part of the day-to-day interactions (the regular role of the DSP)
Formal assessments include standardize tests that have been previously validated and tested in a formal research environment. Formal assessments have specific administration and scoring procedures which may require credentialing or training requirements for test administrators.
Informal assessment on the other hand includes observations, interviews, documents/record reviews. These are structured as makes sense for the person and his or her needs. Informal assessments form part of the day-to-day interactions and engagement with a person (the regular role of the DSP).  There are likely some common assessment methods and strategies that you already use in your work. Can you think of a few that you use today?

8. Common Formal Assessments
Medical or Health Assessments:
Measures physical and functional capabilities such as vision or speech. These may include diagnostic procedures such as testing for blood sugars or drug testing.
Psychological Assessments:
Measures neuropsychological, behavioral, social, and emotional skills and abilities. Mental health screenings (mental health diagnosis) and chemical dependency tests are often a part of psychological assessments.
There are several different methods of assessment. For this course, we will discuss assessments methods that are directly related to physical and mental health since that is a focus of NADD’s work and support for people with co-occurring IDD/MI. These are clinical assessments. In addition, it is important to ensure all practices are delivered through a person-centered lens to discover what is important to the person and what matters most to them.
Other forms include: educational assessments and vocational assessments.

9. Cultural Biases in Services
We all carry cultural biases, intentional or otherwise; try to find and address cultural bias within your speech, or thinking. To be person-centered and accurate in assessment a person’s language, preferences, background, and world views should be included.
Cultural bias exists when we try to guide the experiences of others through the lens of our own (personal) cultural experiences. Cultural bias can affect how we treat the people we support. It can affect our speech and gestures. The first step to avoiding a cultural bias is to understand what it is and accept that it exists. When you work with people your support, reflect on the hidden cultural biases in your speech, manners, or behavior.

10. Examples of Cultural Bias in Assessment
Health/Mental Health
Difference in expressing symptoms
Differences in what symptoms mean
Difference in what is comfortable as far as gender of practitioner
Difference in acceptable use of medication
Difference in resources available
Communication/Behavior
Difference in words, gestures, tone, pace, volume, who to talk to, deference, body language, expressions of emotion, who to talk to;
Person-centered
Who is family, acceptable roles and relationships; rituals and routines, spiritual practices, language, dress, food,
Developmental
Delay language learning in dual language household; familiarity with utensils; familiarity with forms of play; age of weaning
Note: Cultural biases can affect assessment if a person is behaving in a way consistent with their culture but not consistent with the assessor’s culture. The best way to avoid cultural bias in assessment is to carry out what is describe as Cross Cultural Assessment. Prior to beginning assessment, the trained staff should conduct a self assessment of their own biases and prejudices.
Knowing people and their cultural and language needs
Help identify and advocate for person-centered accommodations with practitioners and other professionals
Help identify culturally competent professionals

11. Benchmark 1B: Use of Assessment and Observation Tools
The qualified DSP demonstrates proficiency in the use of assessments and observation methods to support needs of individuals served.
You are the one person who is there on the person’s good days and bad days
You are in a unique position to observe and collect valuable information in a variety of settings (a person’s home, workplace, school, hospital, etc). This information may be unavailable to other professionals.
You are the one person who is there on the person’s good days and bad days. You are well placed to often better understand the person’s communication than other professionals in the persons life do. You may know what is typical for the person and what is unusual.

12. Benchmark 1B: Use of Assessment and Observation Tools
Some common formal assessments that DSPs should be familiar with:
Person-Centered Discovery
Physical Health (medical, OT, Speech, etc.)
Mental Health (diagnostic assessment)
Functional Behavior Assessment (Other: Sensory; learning disabilities; etc.)
Comprehensive Assessment (as part of any behavioral assessment)
This benchmark focuses on how to use the following assessment and observation tools and will provide some examples of engaging in a person-centered process for assessment and observation. For each – describe why they are important; what it does, strengths of the assessment, when it should be used, other important info for DSPs to know about the assessment approach.
A foundation for any person receiving services is person-centered discovery and person-centered practices in service delivery. Having a good understanding of what matters to people, what kind of life they would like to lead, what goals, preferences, and expectations they have, how they like their day to go, who is important to them, how they like to handle things, what works for them in different situation, etc. needs to be part of any service provided and should be part of assessment. Be certain that cultural, ethnic, and linguistic differences are attended to in any assessment situation as well. For people who have ongoing struggles with their health, well-being, or behavior choices, a formal person-centered plan can be helpful in filling in the missing pieces to helping people use their services and supports in a way that creates a life they enjoy living.

13. Basic DSP Skills for Assessment
In all forms of assessment (both formal and informal) you will use the following skills:
Observation
Checking with the person (Interviews)
Communication
Documentation
Presenter: these are the 4 basic components of a DSP assessment---observe a person, check with that person, communicate with someone, and document someplace
You may use these skills to provide information to a practitioner doing a formal assessment.
You may use them to track information critical to the person and team.
You may use them to make good decisions about what to do next.
You can use these at your next staff meeting and have a contest to see how others are close to your assessment facts

14. Core Skills For Daily Success
Knowledge of common formal assessment
Understanding of critical status changes
Recognizing medication side effects or other problems
Behavioral and clinical signs and symptoms of a medical or mental health conditions onset or crises
Presenter: Challenging behaviors are driven by an underlying change in physical or mental health status. These are the two primary reasons for all of us not just persons with a dual diagnosis.
So, recognizing this important point, means that a person’s mental or physical health is changing. A DSP must be able to discriminate between the two. It’s important to consider underlying physical or medical changes (such as pain, physical ailment or mental illnesses, etc.).
Whenever there is a sudden or dramatic change, when change is progressive, crosses over multiple environments or situations, and/or endures for more than 2 weeks.
What skills will DSPs need to monitor for medication side effects? If you pass medications now you need to be aware of what side effects may play out in the behavior of the person with a dual diagnosis.

15. Participating in Formal Assessments
As a DSP, you may be required by your organization to assist a professional assessment administrator (clinician, behaviorist) in gathering assessment information.
Before participating in formal assessments:
Make sure you understand requests
Clarify expectations as needed
Follow directions and pay attention to specific details
Be objective
Report and or communicate person-centered information
DSP’s who might be a participant in a formal assessment should understand how to support someone (preparing, doing the assessment, following up) – DSPs should be familiar with the assessment, know the person’s preferred communication style and processing needs, work with the assessment professionals, advocate for adaptations/use of communication approaches as necessary, bring documentation, etc.
The key to preparing for assessment is identifying key participants. DSPs often know the person well. They should and can be part of assessment process. The DSP may also support the person in thinking about who the person wants involved or not.
Only a person with professional training in administering assessment is allow to conduct formal assessments. DSPs can only assist with formal assessment, unless they have proper training and credentials to perform formal assessments.

16. Learn the Signs and Symptoms of Mental Illness
One half of all mental illness begins by age 14 and 75% begins by age 24 (American Psychiatric Association) .
Mental health illnesses like schizophrenia or bipolar disorder usually do not occur suddenly. Symptoms are less observable than anxiety. A person will usually begin to notice small changes or a feeling that something is not normal or right about their thinking, feelings, or behavior.
They will usually begin to realize some of these symptoms before these illness are fully developed. For example:
Presenter: Discuss signs and symptoms of a mental health diagnosis as the slide presents. Take questions from participants before moving to the next slide.
Remember, if a person is experiencing suicidal thoughts or intent, or thoughts of harming others, seek immediate attention. Report your concern to your supervisor and the police immediately.

17. Common Signs and Symptoms of Mental Illness
Unusual behavior
Withdrawal
Drop in functioning
Problems thinking
Nervousness
Increased sensitivity
Mood changes
Apathy
Feeling disconnected
Illogical thinking
Sleep or appetite change
As a reminder; observing a person with one or two of these symptoms alone does not necessarily determine or predict a person’s mental health condition. However if you suspect a person to be having several episodes of these symptoms at one time, and the symptoms are causing serious problems in the person’s ability to function, they should be seen by a mental health practitioner. Discuss how participants would be able to look for these signs and symptoms in persons with limited communication. Ask participants for specific examples on what they would noticed in a persons behavior.
Unusual behavior – a person may begin to experience odd, uncharacteristic, and peculiar behavior
Notes:
Withdrawal — a person may suddenly withdraw from social activities and lose interest in others
Drop in functioning — An unusual drop in functioning, at school, work or social activities, such as quitting sports, failing in school or difficulty performing familiar tasks
Problems thinking — a person may suddenly begin to experience problems with concentration, memory or logical thought and speech that are hard to explain
Nervousness — Fear or suspiciousness of others or a strong nervous feeling
Increased sensitivity — a person may experience or report heightened sensitivity to sights, sounds, smells or touch; avoidance of over-stimulating situations
Mood changes — a person may experience rapid or dramatic shifts in feelings, or mood swings
Apathy — a person may lose motivation in taking initiative or the desire to participate in daily activities
Feeling disconnected — a person may begin to experience vague feelings of being disconnected from oneself or one’s surroundings; a sense of unreality
Illogical thinking — Unusual or exaggerated beliefs about personal powers to understand meanings or influence events; illogical or “magical” thinking typical of childhood in an adult
Sleep or appetite changes — usually, a person may begin to experience dramatic sleep and appetite changes or decline in personal care (personal hygiene).

18. Signs and Symptoms to Look For
Look for signs of changes in the person’s health status. It is also important that you know when to get involved. For example, you notice the following:
Appearance (flush, rash, glassy eyes, weight changes)
Behavior (increase or decrease in preferred, non-preferred behavior)
Activity level (how busy, lethargy)
Communication (ability, drive to, methods)
Sleep-changes—unable to sleep, sleeping much more, interrupted sleep, change in time of bed or wake
Mood—irritability, attention, activity level, patterns of speech
Appetite—more, less, cravings, binges, etc.
It is important to know that behavior, understanding, thought processes can be affected by symptoms of mental illness.  Always document changes in the persons behavior as you observe them. You should record your observation as accurately as possible without jumping to conclusions. It’s okay to observe changes and not have an immediate answer. It is important to know that behavior, understanding, thought processes can be affected by symptoms of mental illness.  
You the (DSP) should be familiar with the whole competency and know how it applies in your workplace but what’s really important is your attitude toward the person you are observing. When someone has ID/MI it takes more effort. It is more of a challenge for you and other DSPs.

19. Benchmark 1C: Behavioral Assessment
The qualified DSP recognizes behavior as a form of communication. The DSP demonstrates proficiency in observing and recording behavior. The DSP is able to summarize and analyze behavioral assessment information. The qualified DSP collaborates in the planning and implementation of interventions and services aimed at increasing desirable behavioral skills.
Behavior is some form of communication so you are critical in helping the overall understanding of a person who has challenging behavior. If something has changed, a direct support professional has information as to why.
How many observations can you make in a traditional 8 hour shift? 1, 5, 10, 20, 100? You are observing all the time and are aware of what is happening with an individual and their day more than you can count. Your observations are the “first line of defense” against restrictive procedures being implemented. So once you have an idea of what is causing the challenges, you will have to document it someplace, then report it someplace, or call someone right away, and continue to provide reassurance to the person you work with – that is our commitment and allegiance to people we support. The goal in this skill standard is to assess the situation, observe the person served, and report it up right away to others who can help people get their needs met.

20. Behavior Assessment
Behavioral assessment (especially functional assessment) involves direct support professionals as key informants and observers of a person’s behavior in their environment.
It is important that DSPs observe an individual in different settings, situations or circumstances.
But it will be your observations of what the person was doing before you provided that intervention and occurred after that are critical.
DSPs support behavior in a number of ways: e.g. by intervening in a respectful way by redirecting to something that is more soothing or more functionally appropriate like a walk outside, engaging in deep breathing, taking a break.
But it will be your observations of what the person was doing before you provided that intervention and what they did after you provided that intervention that are critical.
Optional to add in this below: Informally here are some considerations to think about:
What’s happening now, Are people uncomfortable, in pain, bothered by something, hungry, did something just happen?
Tuning in to human needs/pay attention to the person, checking for signs of discomfort, illness, (fever, rash, cut. etc.)
Are these signs of emerging mental or physical conditions the person previously experienced?

21. Behavioral Assessment
During behavioral assessments, patterns are identified and recommendations are made for behavior prevention and modification.
The most common types of behavioral assessment include:
Clinical or psychological assessment
Functional Behavior Assessment (FBA)
Your observations and assessment can lead others to helping the client too. For example, this client may see a psychologist for 1 hour a week to address challenging behavior.
You can attend that session and provide your observations of that client:--when does he get upset, what time of day does he get upset, what is the environment like when he gets upset, how many persons are with him, etc. all of these questions (and more) might be asked. If you can answer them for the psychologist or therapist you are a key piece of the assessment and a large part of a bigger question: how can I help this person do better, lead a better quality of life?
DSP’s frequently participate in something called a Functional Behavior Assessment. We will discuss that now

22. Functional Behavior Assessment
A Antecedent B
Behavior C
Consequences
Functional behavior assessment is generally considered to be a problem-solving process for addressing challenging behavior. It relies on a variety of techniques and strategies to identify the purposes of a behavior and to help teams identify interventions that directly addresses the problem behavior. CECP (2001)
FBA is a process for identifying:
Observable problem behaviors, the most obvious thing we see in our clients
The contexts or routines where the problem behaviors are most likely to occur
The specific event with in the event (setting) that triggers the behavior
The consequences that appear to maintain the problem behavior

23. The ABC Method
The ABC method is a direct observation approach that can be used to obtain information about what influences behavior
"A" refers to the antecedent, or the event or trigger that immediately precedes a problem behavior.
The "B" refers to observed behavior, and "C" refers to the consequence, or the event that immediately follows a response.
These will be review in more detail in the following slides.
The ABC method is a simple and quick tool to track your assessment and observation. IT IS A COMPONENT OF THE FBA.
While it might be considered a behavior support technique, the ABC method can be used to document symptoms, health, and other conditions where observation is essential to tracking patterns.
DSPs should be familiar with these three letters or symbols for challenging behavior.

24. What is the Purpose of an FBA?
The main purpose of an FBA is to improve the effectiveness and efficiency of supports.
Understand what need a person is meeting through his or her behavior.
The functional behavior assessment should look beyond the behavior itself. The focus should be on identifying significant, individual-specific, social, affective, cognitive, and/or environmental factors associated with the occurrence (and non-occurrence) of specific behaviors. CECP (2001).

25. Antecedent
Explains why the behavior is occurring now as opposed to some other time (a setting event may contribute but is not direct cause)
Pay close attention to the person
Check for signs of discomfort, illness (fever, rash, cut, etc.)
Are these signs of emerging mental or physical conditions the person previously experienced? (i.e. a symptom, side effect)
Understanding the antecedent events that are associated with both the occurrence and nonoccurrence of problem behavior can help you modify the characteristics of a difficult situation. The antecedent events that trigger positive behaviors in one setting like home can be introduced into another setting like a sheltered workshop and be associated with disruptive behavior.
Common Antecedents: Told to do a task
Failure to complete task
Reprimanded/redirected
Presence of a person
Victim of aggression
Being ignored/alone
Told to wait
Symptom/pain
Transition from one activity to another
End of an interaction
Told “no”
End of pleasant activity
Teased – called a name
Internal need/feeling
Trauma memory/trigger

26. Behavior
Behavior is how a person acts either toward themselves or toward others. Behavior is externally visible--meaning it is observable, and it can be seen. Behavior can be verbal (talking, shouting, swearing) or non-verbal (biting, hitting, smiling, walking, punching, waving, etc.) For assessment purposes, it’s important to give an objective description of behavior. What can you see and describe without bias?
Behavior for us and our clients is the most observable part of our day but often the most misunderstood or misinterpreted.
You must provide a clear and concise definition of the behavior for others to understand, using some examples from everyday experiences. The objective for a DSP here is that the behavior is documented clearly and defined in operational terms.
Here is an example of how ambiguity or confusion about a clearly observable behavior can be problematic “John is hitting his head” can mean: against a wall, on his desk, with his fist, with an open hand, head-butting, etc.

27. Consequences
The consequences that follow a challenging behavior include everything that occurs as a result of behavior. It includes the changes to the person or setting.
The feedback or action taken by the learner could also be part of a consequence that followed the behavior.
For example, the consequences for spilling water on the table during dinner may include
A wet table/water spilling on the floor
Others yell and step away from the table
Someone touches your hand as they help you wipe the table
It is important to note that when we discuss consequence, we are not only talking about some type of punishment for the person with DD who has challenging behavior.
We are talking about what happens following behavior….what does that client do? retreat, sleep, pace, leave, get hurt, get relieved of a task? This is important information for assessment and support. If we can teach the behavior that you observe at the end of an upset mood or challenging behavior, we might encourage that coping strategy before the challenging behavior occurs. Sounds simple right? But you can only get there if you observe and assess frequently and proactively.
EXAMPLE: If a person likes to relax in their room with the TV on and frequently does this after being upset, then the next time they appear to be heading toward a challenging behavior, you can move in quickly and offer this option for them before things get out of control.

28. 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.

29. Communication
Assessment information should be shared or communicated with other professionals, including the person and members of their team.
Communication with internal and external team members must be timely and professional.
Communication should be objective; non-judgmental and accurate.
Note: Please consider the privacy of the person when sharing information about them.
Presenter: You should develop a system for sharing and communicating assessment information with the person, family members, and other professionals ( behavior specialist, case managers, etc). Follow your organization’s specific policy on reporting confidential information. Assure confidentiality of assessment and observation information. Also discuss when, how, and with whom to communicate and the effectiveness of this communication.

30. Differences in Communication with Different People
Person—make an effort to engage the person with language he or she prefers
Coworkers/supervisor—know proper terms to use, keep discussions and information confidential, use documentation as well as face-to-face discussion
Family?
Professionals?
All four of these categories require different communication. Some of these persons will require internal communication while others require external communication, and the differences are very subtle. But you may have to tell another professional like a social worker or psychologist more details than a family member about a person with challenging behavior. Your agency will have some policies or guidelines on how to communicate with different constituents that touch the lives of our clients.
Activity: You will want to remember and apply the NADSP Code of Ethics.* The area of the NADSP code that covers this area is documentation and confidentiality..

31. Documentation
Documentation includes information (meaningful data) and its supporting medium, which could be in the form of
Paper
Audio
Video
Pictures, etc.
Documentation also involves recording, capturing, storing, or printing information.
Documentation involves your ability to accurately record and store assessment and observation information. In your role as a DSP, it is important that you practice helpful documentation and good record keeping practices. This helps other team members to keep track of assessment and observation information and be able to make an informed analysis.
The DSP’s documentation should be legible, legal, person-centered, objective, culturally sensitive, and organized.

32. What is Helpful (Good)Documentation?
Helpful (good)documentation is accurate, legible, and objective documentation of assessment and observation information.
For this course, helpful documentation is person-centered, objective, culturally sensitive, and organize.
When engaging in documentation, do not use technical terms that others on the team may not be familiar with.
Each time you write, you take responsibility for your work and what you have written by signing or initialing. Ensure the information is truthful and accurate to the best of your knowledge
Explain the difference between helpful and unhelpful documentation. It is important to know your agency’s policy and procedures on documentation. Each agency has a unique documentation system and some unique requirements. Many agencies are using online or web based documentation systems.
Whether it is paper or an online system you documentation cannot be unhelpful…meaning it cannot be biased, incomplete, vague, incomplete, incorrect, prejudiced.

33. Unhelpful Documentation
Unhelpful documentation is documentation that lacks significant user information that clearly explains the Who, What, Where, When, and How
Unhelpful documentation is confusing, vague, and unclear.
There are consequences to bad or poor documentation.
An example is the person loosing or missing out on treatment or opportunities because of missing information or records.
Presenter: Unhelpful documentation is documentation that lacks significant user information that clearly explains the Who, What, Where, When, and How (sometimes Why). Five years from today you probably would not remember the individual you work with. But current staff, or your manager will have to rely on your notes from 5 years ago.
Helpful documentation is error free, legible, and answers the who, what, where, when, and how questions. It includes the user’s signature or initial.

34. Example of Helpful (Good) Documentation
Helpful documentation is error free, legible, and answers the who, what, where, when and how questions. It also includes the user’s signature or initial and date. When documenting behavioral observations, it is important to include an operational definition of behaviors, as well as the frequency, intensity and duration of the behavior.
Helpful example
Not helpful example
Melissa left the table early 5 times last week during dinner and went to her room. She screamed and cried in her room for minutes each time. Once, she knocked over her dishes before she left.
Melissa left the table mad and was depressed in her room after dinner most nights.
Here are concrete examples of helpful and unhelpful. Discuss the differences.
When documenting frequency, it is important to document how often the problem behavior occurs during a specific time period (as opposed to “most nights”).
Additionally, intensity looks at documenting information about the strength, power, or force with which a problem behavior is occurring. You might ask these questions to help the participant understand intensity: Is the behavior affecting the person’s ability to form and maintain relationships? Is the behavior so severe that it is impacting the person’s ability to partake in activities of daily living? (10-15 minutes is meaningful for Melissa)
When possible, document the time between the start (beginning time) and an end time of the behavior. Work together with your coworkers to share and collaborate with observations to provide “helpful,” meaningful observations.
Our goal: In the living or work environment, ask yourself and others what’s working and what’s not working in this example, and what they would do differently to make this documentation helpful.

35. Treat It As A Legal Document
Think of an assessment document as a legal document. Poor and illegible documentation can not only hurt the person, but can bring on some legal challenges for you or the organization you work for.
All forms of documentation are legal systems and legal documents. They should be written with this in mind. On line documentation systems also have the same legal authority. They can be used in court, they can be accessed by state and federal inspectors.

36. When and What to Document
It is important to document sudden and unexpected changes in a person’s behavior.
When you notice changes even if you think it might go nowhere, when needed as far as mental health symptoms or signs of illness, etc. (changes in health status)
Track usual (baseline) and unusual changes in diet, weight, sleep pattern, behaviors, possible medication side effects.
Where documents require data entry, these entries should be clear, legible, and include your signature. You also want to document assessment and observation information. Once you document assessment and observation information please share it right away with appropriate team members. Check with your employer for specific policies and guidelines.
You should be able to separate and prioritize essential and non-essential information documenting.

37. Sharing Assessment and Observation Information
Much of the information you will gather is confidential information. Read your organization’s policy on confidentiality prior to sharing assessment information with unauthorized individuals (this can include anyone with whom the person does not give consent to share). There are times when information is useful and relevant and can help someone get needed support.
Talk to your supervisor regarding organizational policies and be aware of specific state or federal policies on HIPAA/confidentiality. Again consult the NADSP Code of Ethics on this area and be completely aware of these guidelines.
It is important that you are respectful and person-centered in your documenting of information about your client.
Ask yourself these questions:
Is my client ok with the information I share about them?
Why is it important that this information be shared?
Do I seek their permission to share sensitive information with others?
Am I totally safeguarding my clients confidentiality with this documentation.

38. CONCLUSION
Thank you for participating today in this NADD webinar Please plan to attend the next one and the entire series. If you need to contact today’s presenter please do so with this info below: Tony Thomas, Executive Director, Welcome House, Inc. 802 Sharon Drive, Suite A, Westlake, Ohio Phone: , ext