Saturday, March 25, 2017

Documentation


            This week, I have continued to do my usual crisis line shift and co-facilitating one of the children’s group.  One of my supervisors also opened up two intake slots for me, and I was able to do my first intake completely on my own!  It was liberating!  Preparing for my intake was challenging because I was very nervous, but it went fairly smooth and I believe I got all the information needed!

            The two biggest challenges I faced this week were the managing a lot of paperwork now that I am having more client interaction, as well as maintaining my composure and facial expressions when having in person client meetings.  Paperwork has been a challenge because it is important to fill it out correctly, file it in the right spot, and have copies given to various counselors and provide referrals to groups and individual sessions.  It’s a bit overwhelming, but I’m gradually getting the hang of it.  Managing my facial expressions has been sort of challenging because I’ve been told that I display all of my emotions all the time.  So when a client tells me a rough story, or shares something that I was not expecting I need to be conscious of my expression so they can trust me and not sensor what they share.

            Similar to last week, this week was rewarding because I am continuing to get more responsibilities as my time at Sarah’s Inn goes on.  I have two crisis line shifts a week, I am able to assist in planning children’s group as well as do the paperwork for it, I now have two intake slots, and I will be helping organize files for an upcoming audit.

Documentation

            Everything that clients are part of, or any service provided is documented.  Progress notes are kept, service plans and evaluations are updated every couple of months, and everything is kept neatly in each clients files.  If an injury happens at group or in the building before or after an event, we fill out a critical incident report to document any and everything that happens to show that we addressed and fixed the incident.  Recently, there have been updates to a majority of paperwork, so there has been some confusion for everyone.  I am not sure who created or how the paperwork came about, but everyone is capable of requesting improvements depending on client needs and needed information for better service delivery.  Documentation helps us better serve our clients, and if a different advocate needs to work with a client they can find all the information they need from their file.  Also, if these files are subpoenaed, what we document can help our clients prove abuse if they are trying to get and order of protection, gain custody of their children, or get a divorce. 

3 comments:

  1. Sarah,

    I am so happy you got to do your first intake! That must have been so exciting! You should feel very proud of yourself for doing that, because it can be a very daunting task- and you handled it like a champ. You deserve to get all of these new responsibilities. The paperwork thing is something that I have slowly gotten the hang of too. I found that it is really helpful for me to make lists of all the kinds of paperwork that I do and the different parts that go into them and keep them in the drawer of my desk so that when I need to do certain types of paperwork I can whip out my post-it note and make sure I got every single part. I agree with your facial expressions- I have found it so hard to not react to some of the things patients tell me- but I feel that is a skill that develops over time as you get more exposed to things in the field. I am glad that your agency heightens the importance of documentation. It is really important to have things recorded because if you do not, there is no proof that anything was done. I also think it's great that your agency allows requests for improvement to documentation- it shows that your agency is open to change so that it can better help clients in need. Keep up the great work, Sarah!

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  2. Sarah-
    I have also gotten feedback on managing my facial expressions. It can be really difficult to do at times, but it is good you have someone who recognized it and was able to give feedback about it. Doing your first intake on your own sounds very exciting! It sounds like you are doing a lot of really cool stuff at your placement!

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  3. Sarah,
    I am sure you will be able to continue to work on your facial expressions. It is something that comes more naturally with time. As your confidence continues to grow you will be able to hold the stories of the women and the children that you work with very well.

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