Please document his actions and attitudes

David is on a track to potential discharge in March of 2016.  I won’t go in to the ins and outs of his program.

I don’t necessarily agree with discharge at this point.

David has been having difficulties the last two days.  And a couple of times over the last month.

If his care and issues aren’t properly documented, my fear is that he will not get the care that he needs.  His behaviors are escalating.

Please, don’t do him any favors by not documenting his care.  If he does something, please document it.  It is the only way to ensure that he is getting the care he needs.

We saw this in his last placement where things weren’t documented in the lodge/cottage/residence.  He ended up being discharged against doctors orders because Medicaid said he needed to go home since he wasn’t making any progress and was not regressing either.

Document, document, document…

Merry Christmas.