Communication - Logs and Records

«Home»

Logs

There are a variety of logs that are used at the Shelter. They are:

1. the Shelter Log
2. the AOM/Assistant Log
3. the Brief Service Log
4. the Client Log
5. the Medications Log
6. the CPS Log
7. the Phone Log, and
8. the Resident Log

Except for the Resident Log and CPS Log, the logs listed above are official agency records. The information contained in all of the Logs is confidential; staff are to adhere to the confidentiality policy with regard to what they read in any of the Logs. All of the Logs serve to provide information about the residents and serve to provide a means of communication among the staff. All clients and their guardians have a right to see the Log entries which pertain to them. For further detail refer to the write up on the Access to Client Files Policy on the first page of this section

«Back To Top»

shelter log

The Shelter Log is basically an account of the daily occurrences of the Shelter. The Shelter Log is divided into 4 sections:

1. Temporary Exits
2. Possible Admissions
3. Daily Log Entries for each shift, and
4. Staff and emergency phone numbers, referral phone numbers and miscellaneous information.

The OMs, the Director, the Shelter Manager, and the Counselor regularly record information in the Shelter Log. The Assistants and AOMs have their own Log. The OMs, Shelter Manager and Counselor are required to read the Shelter Log each work day; other agency staff read the Log as it relates to their duties.

The Shelter Log is to remain in the OM office and away from the residents. Residents are not routinely allowed to read the Shelter Log. Any resident who insists on reading Log entries about him/her should be referred to his/her Case Manager. The Shelter Log is an official record. Parents, case workers, probation officers and residents can obtain authorization from the agency to read the Log. Also the Log could be used in court. Staff are to be observant of this fact when writing their Log entries.

Temporary Exit

The Temporary Exit Sheet is used any time a resident temporarily leaves the Shelter with someone other than a staff member for an appointment or visit. When this occurs, the OM should record the following information on the Temporary Exit Sheet:

1. resident's name
   
2. who the resident is leaving with and the reason the resident is leaving
   
3. date and time of exit and the OM initials
   
4. date and time the resident is expected to return

When the resident returns to the Shelter, the OM should note on the Temporary Exit Sheet the date and time of the resident's return and the OM's initials. OMs also note in their Log entries information concerning temporary exits. There is an example temporary exit note in the example OM Log Entry, which can be found in the succeeding pages.

When a resident temporarily leaves the Shelter with a staff member for school runs, appointments, activities, etc. a note is to be recorded in the OM's Log entry. An example of this is provided in the Example Log Entry referred to in the preceding paragraph.

Example Temporary Exit Sheet

Resident's Name	Reason Leaving & Name & Sig. of Person Resident With	Exit:Date,Time OM initials	Expected return time	Return:Date,Time OM Initials
Sue Johnson	w/case worker to crt. Lisa Smith	6/24/93 9:15am L.K.	6/24/93 11:30am	6/24/93 11:40am L.K.

«Back To Top»

Possible Admissions

The Possible Admission section is used to record information concerning potential admissions to the Shelter. The only information about a possible admission that needs to be in the daily Log entries is a short note directing the reader to get more details from the write up in the Possible Admission Section. An entry in the Possible Admission section should include:

1. Date of contact
2. Youth's name and age
3. Who is requesting placement
4. Reason for referral/presenting problem
5. Pertinent background information on the youth and/or family, such as history of violence, drug and alcohol use, etc., is youth a recid., any siblings in the Shelter in the past, other residential placements, etc.

If such information is recorded on a Brief Service Record, staff should make a note in the Possible Admission section to refer to the Brief Service Log.

Example Possible Admission Entry

5/7/93 Susan Jones - 14 y.o. female. (M) called requesting placement at the Shelter. Susan is not going by house rules; she sneaks out of house at night at least once a week. (M) thinks she goes out with BFr. Susan not doing chores at home and argues frequently with (M) and her younger sister. Susan also is regularly cutting classes in last 2 months, although no past history of truancy. Susan goes to Batchelor. Today Susan did not return home from school. Suggested to (M) to file apprehension form. We agreed to admit Susan when she is picked up.
(M) thinks Susan may be using alcohol and drugs infrequently. Susan has been on probation a year ago for shoplifting. There is no history of violence or suicide.

«Back To Top»

Daily Log Entry

The OM completes a Log entry for each shift he/she works. The Director, Shelter Manager and Counselor record entries in the Log as need to communicate information about the residents, the program or policy and procedure. All OM Log entries are done on the computer, unless weather or a malfunction prevents the OM form using the computer. Staff will be trained to use the computer for the daily log entries. There is also some information about daily log entries on the computer in the Word perfect Program, WP51, subdirectory, "LOG", file, "LOGEX". It is usually more efficient for the OM to work on his/her entry throughout his/her shift, typing in phone calls, showers, medications, visitors, school run, groups, etc. as the activity occurs. All daily Log entries are to include the following information in their heading:

1. date
2. day
3. shift hours, e.g. 8 AM - 4 PM
4. OM's name, and
5. the names of the Assistants and AOMs who worked.

An example OM Log entry is provided in the following pages.

Daily Log Guidelines

1. GENERAL INFORMATION
• Things that need general circulation, e.g. a new Shelter procedure or reminders about a policy.
  
• Shelter maintenance Information, e.g. plumber fixed disposal or toilet stopped and staff plunged it.
  
• Possible Admissions: Short note directing staff to a write up in the Possible Admission section.
  
• Crisis calls: A short note directing staff to write up in the Brief Service Log or to counseling notes if it is an ex-resident or client of another Youth Service Bureau program.
  
• Youth Shelter School: List the residents attending YSS and if they got their positives. Record status of non-residents on YSS Attendance Sheet. Note any behavior problems presented by any student.
  
• Curfew Calls: A short note indicating if calls were made. On the Monday day shift, record whether a Probation Officer called to check on status of curfew calls.
  
• CPS Calls: A short note indicating a 310 filed or On-Call beeped. Note when it appears that DPW needs to pick up 310's.
  
• Director, Shelter Manager, Counselor Notes: to communicate important information about the Shelter or the residents.
  
• Staff Meetings Announcements are recorded in the Log.
  
• Security Checks: Note check was done; also note any problems, e.g. doors unlocked, copier on, etc.
  
• Contact with On-Call: Note any time YS On-Call is contacted and the results of that contact, e.g. On Call ok'd a visit, or talked with a possible admission.

«Back To Top»


2. SHELTER RESIDENTS
• Resident phone contact, both incoming and outgoing calls.
  
• School Runs: Overnight OM records what time the van leaves the Shelter for AM school run. Daytime OM records the order and times the resident were dropped off at their schools in the AM. The OM on duty when the residents return from school records info. re: afternoon school run - which staff drove, order residents picked up, etc.
  
• Daily Tally: Overnight OM lists each resident's tally.
  
• High Positive Winner: Overnight OM puts a star by resident's name with the highest positive tally.
  
• Special Activity Winners: Friday overnight OM notes which residents won Special Activity.
  
• Visitation in Shelter: Note name and relationship to resident of visitor.
  
• Out of Shelter Visits or Appointments: such as resident goes to church, resident goes to Probation Officers appointment: Note the time the resident leaves and returns, who resident leaves/returns with and where resident is going/went.
  
• Away from the Shelter Activities: Note which residents and staff went, what group did and at where.
  
• Resident Showers: List who took shower.
  
• Bed Checks: Note time of checks.
  
• Resident Medication: Note who received medication. If over counter medication given, note to whom and for what complaint.
  
• Write-up on each Resident: Describe behavior and attitude. Note how well resident complied with program. Describe how resident interacted with staff and other residents.
  
• Crises, Major Behavior Problems, Medical Problems: Note when a resident placed on setback, when a resident is ill or injured, when a resident runs away, when a resident becomes so upset he/she needs to talk with On-Call, etc.
  
• Resident Groups: list who was in which group and if group compositions worked.
  
• Admissions: Note the
  1. time of admission
  2. youth's name, age and if youth is a recidivist
  3. who referred youth to YS, i.e. parental, court order, DPW, etc.
  4. reason for referral/presenting problem
  5. school resident attends
  6. health issues, including medications, conditions, treatment, etc.
  7. pertinent background information on the youth and/or family, such as history of violence, drug and alcohol use, learning disabilities, any siblings in the Shelter in the past, other residential placements, etc.
  8. any other significant information, such as mood at admission, contact with On-Call, etc.
• Discharges: Note time of discharge, with whom resident left and where resident was going.

«Back To Top»

Example Daily Log Entry

FRIDAY, 8-24-93, 4pm-12am, ANN w/JOHN, KATHY & TODD

SCHOOL RUN:Jill & Lee>North, Brian>Batchelor, Kathy>South, Sam>Tri-North, Chad>Edgewood Jr. High
*Searched residents.

T-FORM: Checked Sam's t-form. a.o.k.

TEMP EXIT: Lee w/Kathy to MHC @ 4:30pm, Kathy w/M to Dr. Smith @ 4:45pm

MAINTENANCE NOTE: Toilet upstairs backed up. Plunged it but stool still draining slowly.

RETURNS: Lee w/Kathy from MHC @ 5:45pm; Kathy w/M from Dr. @ 6:15pm. Brought back a new script for Birth Control pills. Takes 1 every AM. Med's inventoried in.

PHONE CALLS:Jill>>Mom, Beth(friend), Brian<>SM, Sara<>Todd(Bfr), Chad<>Brother, Jack>>Sis>>M>>Carrie(Gfr)

POSSIBLE ADMISSION: Deanna Jones. See P.A. section, 8-24-93

ACTIVITY: Group 1 - Kathy & Todd w/Jill, Kathy, Brian to Classic Bowling Group 2- John w/, Chad, Susan, Sara, & Lee to Classic Bowling

BEHAVIOR INCIDENT: During chore Sam & Brian got into an argument b/c Brian kept calling Sam names. Brian got negatives. Then while Sam was doing living area, Brian kept messing up newspapers & books. Brian given a 15 minute time-out, but Sam went off. Sam started calling Brian names, then ran to his room & punched a hole in the wall. Gave Sam a 2 hr. mini- setback. Initially Sam refused to come out of his room & serve his min-setback, but came out w/in 10 minutes. Had him serve his mini-setback in the kitchen, for better supervision.

MED.'S: Jack-as prescribed, Lee-tylenol for headache
Sam-as prescribed, Susan-ibuprofen for cramps

CURFEW CHECKS: Done by John

SHOWERS: Jill, Kathy, Sam, Chad

RUN: Kathy @ 10:35pm. Found missing between 10:15 & 10:35pm bed checks. Porch window and screen door unlocked

P's	App	BPD	Clothes
x	x	x

IN GENERAL: An ok night, but a little hectic due to conflicts b-tween Sam & Brian, then Kathy running away. Still pretty smooth for having 9 kids.

SAM: Definite scape goat of the group. Continues to need a fair amount of 1-on-1 attention & supervision to get him through the schedule. Behav. very up & down, initially got very upset b/c others picking on him, after mini-setback he was better. Drew while on setback. He's a good artist. Seems somewhat homesick.

JILL: Coop & on task. Seems more mature than rest of the group. Seemed to have a good phone call w/M. Can be calming influence on the others.

CHAD: No real prob. Although he's nicer than other guys to Sam, he can get into picking on Sam, just so the other guys won't pick on him. John helped him as he was struggling with his science home work.

LEE: Definitely the leader of the group, but hard to catch him doing stuff. Egging on other guys to give Sam a hard X. Overheard him talking on the phone w/his B. about partying. Warned him that was inappropriate. Doesn't seem at all concerned with Mon.'s crt. hearing. Very sarcastic @ X's. Lost 1 study time positive b/c he didn't get much work done.

SUSAN: No prob.'s. Seems to be buddies w/Sara. Really knows her way around the kitchen; did a great job on dinner. C/O of cramps after return from activity. I let her go to bed @ 9:30 b/c of cramps.

KATHY: Having a hard time fitting in. She doesn't get picked on the way Sam does, but doesn't really hang out w/anyone. Mostly keeps to herself, reads & writes alot. Doesn't join in on group activities, like cards & doesn't really talk much. Didn't have a clue she was running away. P's agreed to go sign app. They asked she return to the YS once she's picked up. They have a couple ideas on her whereabouts & will tell the police.

BRIAN: Behav. up & down. Really into picking on Sam, but I think he's set up alot by Lee. Enjoyed setting Sam off tonight. Seems to have a crush on Jill. It doesn't seem out of hand & Jill definitely doesn't feed into it. Struggling with his math. Mad @ SM after phone call, but I don't know about what. Needs to be kept apart from Sam & Lee as much as possible.

SARA: No big prob's. Hangs w/Susan. Kinda flirting w/Jack. Laughs when others pick on Sam. Easily distracted by anything & had to be redirected on her chores & during study time. Cried during phone call w/Bfr.

JACK: Seems like he's still trying to figure everything out. Won't challenge Lee's leadership, but doesn't seem as easily manipulated. Flirting w/Sara & trying to show off by telling some "tall tales". M brought his school work in around eve. snack. Did well on chores.

BED CHECKS: John upstairs until all guys asleep, around 11:15pm. 10pm, 10:15pm, 10:35pm, 11pm, 11:30pm (all asleep), 11:55pm.

SECURITY CHECK: a.o.k. Food up by John.

GROUPS: Susan, Jack, Jill, Sara, Brian, Kathy, Lee, Chad, Sam
* Groups only changed for activity. Sam on mini-setback and Jack on hold.

BED CHECKS: John upstairs until all guys asleep, approx. 11:15pm. 10pm, 10:15pm, 10:35pm, 11pm, 11:30pm (all asleep), 11:55pm.

SECURITY CHECK: a.o.k. Food up per John

«Back To Top»

Using the Computer for the Shelter Log

1. Enter (Word Perfect) WP51:

   -Turn on the computer: hard drive & screen
   -Type in cd\WP51
   -press>>>>Enter
   -Type in WP
   -press>>>>Enter

2. You should be at a blank screen. The next step is to make the heading. It is helpful if you make the heading stand out by using capitals, or blocking off the heading by placing the cursor on the first letter of the heading and pressing F12 (block) and arrow --> until the cursor is immediately to the right of the last letter of the last word and then use bold F6, underline F8, or increasing the size of the print by using ctrl F8 (font), 1 (size), and then 5 (large), 6 (vry large), or 7 (ext large). Or use any combination of these features.
3. Type up your entry. To make things stand out make sure you leave space between the different topics, such as bedroom maintenance, YSS, activity, etc. You can also make the topic heading stand out by using any of the features discussed above, in item number 2.
4. Its ok to leave the hard drive on throughout your shift as long as you turn off the monitor when not typing. You should save what you've typed before you turn off the monitor. The first time save your entry follow these steps:
   

   -press save>>>>F10
   -at the bottom, left of the screen it will say "Document to be saved:". Type in the name of your document using the following format:
   -type in the directory under which the document will be save>>>>log
   -type in a back slash>>>>\
   -type the current date using numbers separated by dashes>>>>10-18-93
   -after the date type in a letter to identify the shift as follows: overnight=O, day=D, evening=E
   -this is how it looks when you put it together: log\10-18-93d
   -press Enter

   «Back To Top»
   
   
5. Anytime you add something to your entry and you want to save this new as in your entry, follow these steps:
   

   -press save>>>>F10
   -at the bottom left of the screen it will say "Document to be saved: C:\WP51\LOG\10-18-83d" - press>>>>Enter
   -at the bottom left of the screen it will say "Replace C:\WP51\LOG\10-18-83d? No (Yes)"
   -press>>>>Y (yes)

6. Before you print your log, be sure to turn on the printer. You can also spell check and view the document.

   To check spelling:
   -press spell>>>>Ctrl F2
   -to check spelling through out entire document press>>>>3 (document)
   -follow directions on computer for spell check
   
   To view document:
   -press print>>>>Shift F7
   -press view document>>>>6
   -if you want to make changes return to the working document press exit>>>>F7
   -if the document looks satisfactory, then you can print it by pressing cancel>>>>F1
   -now you're back at the print menu
   
   To print:
   -if you have viewed the document and returned to the print menu press full document>>>>1
   -if you want to print form the working document press print>>>>Shift F7
   -press full document>>>>1

7. After printing you will want to exit you document. To exit:
   

   -Press exit>>>>F7
   -at the bottom left of the screen it will say "Save document? Yes (No)".
   -Press>>>>Y (yes).
   -at the bottom left of the screen it will say "Document to be saved: C:\WP51\LOG\10-18-83d".
   -press>>>>Enter
   -at the bottom of the screen it will say "Replace C:\WP51\LOG\10-18-83d? No (Yes)"
   -press>>>>Y (yes)
   -at the bottom left of the screen it will say "Exit WP? No (Yes)
   -if the computer isn't going to be used for 5-6 hrs press>>>>Y (yes), turn off monitor and hard drive
   -if the computer is going to be used within 5-6 hours press>>>>N (no), then turn off the monitor

   
   «Back To Top»
   
   
8. A feature that is useful using a table for a Run Away Chart:
   

   -Place the cursor on the screen on the left margin of the line where you want the box
   -press columns/table>>>>Alt F7
   -press table>>>>2
   -press create>>>>1
   -enter number of columns. The number of columns = the number of boxes, for P's App., BPD, Clothes, P.O., DPW, YS On-Call.
   -press>>>>Enter
   -enter number of rows>>>>1
   -press>>>>Enter
   -now your at the table edit screen, which you need to exit, so press exit>>>>F7
   -type in headings for each box (cell) of the table
   -to type in the table move the cursor into the table and type. The table will accommodate anything you type by making the boxes (cells) bigger as needed. You can center what you type in the box (cell) by pressing center>>>>F6
   
   

   Example Table:
   
   

   P's	App	BPD	Clothes
   x	x	x

9. OMs should refer to the Word Perfect Reference and Workbook regarding other options and features.

Phone Numbers and Miscellaneous Information

This section includes but is not necessarily limited to the following:

1. Staff phone numbers: Unless otherwise instructed staff phone numbers are not to be given out.
   
2. Monthly Activity Schedule: For further details refer to the schedule.
   
3. Emergency and Referral Phone Numbers: A resource for making referrals to individuals asking for help other than placing a child at the Shelter.
   
4. Probation Officer On-Call rotation.

«Back To Top»

aom/assistant log

The AOM/Assistant Log is basically an account of the daily occurrences of the Shelter from the perspective of the AOMs and Assistants. Although it does not usually contain same kind of detailed information about the residents that is in the Shelter log, because the AOMs and Assistants tend to spend more time providing direct care and supervision of the residents, it sheds a different and valuable perspective on the residents.

All AOM's and Assistants are required to write up their Log entries together. No matter how many Assistants work, there should be only one log entry per shift, as illustrated by the example below. Their Log entries are written at the end of their shifts. All Log entries are to include the following information in their heading:

1. date
2. day
3. shift hours, e.g. 8 AM - 4 PM
4. OM's name, and
5. the names of all the AOM and Assistants on the shift

The AOMs and Assistants are required to read the their Log at the beginning of each shift they work. Other agency staff read the AOM/Assistant Log as it relates to their duties.

The AOM/Assistant Log is to remain in the OM office and away from the residents. Residents are not allowed to read the AOM/Assistant Log. Any resident who insists on reading log entries about him/her should be referred to his/her Case Manager. The AOM/Assistant Log is an official record. Parents, case workers, probation officers and residents may obtain authorization from the agency to read the Log. Also the Log could be used in court. Staff are to attentive to this fact when writing their Log entries.

AOM/Assistant Log Format with an Example Entry

Name(s)	Day/Date	Time	With Whom (OM)
E.g. John, Sally, Chris	Thurs. 8/10/93	6-10:30 PM	Becky

GENERAL: Mood of the group, summary of how shift went (use adjectives). Note if went shopping, ran errands, etc.

E.g. No major problems. Everyone interacted ok, although there were a few tense moments.

ACTIVITY: Indicate where group went, which staff supervised, what the group did, time, who went, etc.

E.g. Chris & Sally took Joe, Sue, Dave, and Anne to IMU Billiards for 45 minutes. Minor conflicts with Dave and Joe, but in general, a good activity.

RESIDENTS: Individual entry on each resident. List behavior: Positive, negative, significant. Also, list peer interactions, staff interactions, stories they tell (that are significant), if they went to appointments, activity behavior, etc.

E.g. JOE: (John's comments) needed help but worked hard on chores. Seemed a kinda down after activity; said he argued w/Dave re: pool rules & ended up getting some 's. Could see he & Dave having more conflicts b/c Dave has a kinda know it all attitude. (Sally's comments) worked w/him on math, seems a little slow; talked about his family, said his sis just moved back home after having a baby & now he has to sleep on the couch. No real problems, besides cussing at Dave. (Chris' comments) Dave kept making comments implying Joe doesn't know how to play pool. Joe tried to ignore Dave, but Dave wouldn't let up. Joe cussed at Dave & rec'd 2 negatives. Agree that he and Dave may continue to get into it.

E.g. SUE:(John's comments) Seemed in a good mood all night. Possibly has a crush on Joe. Enjoyed activity, pouted at first when OM told her she couldn't change outfit b-4 we left. (Sally's comments) Caught her writing a note to Joe, rec'd a neg. Gave note to OM. Good on chores. Showed me some pictures she had drawn; appears talented. (Chris' comments) Helped her w/math, says she's skipped math class alot so she's behind in her work & work seems a little over her head. Joe doesn't really seem to respond to Sally's crush.

«Back To Top»

brief service log

The agency receives in person and phone inquiries from youth experiencing problems and from persons associated with such youth concerning:

1. services provided by the agency
2. other community sources of help, and
3. help for an immediate crisis.

The agency also receives in person and phone inquiries from adults experiencing problems not necessarily related to youth, but rather, concerning community resources for help and help with their own immediate crises. When it appears that the initial contact may or will be the only service provided by our agency, staff should complete Brief Service form.

Completed and blank Brief Service forms are located in the Brief Service Log in the OM office. Extra blank copies are kept in the file cabinet in the OM office. If a followup contact is required, staff should place the in the Executive Director's or Counselor's box. If additional service is given by the agency and a case file therefore opened, the completed form is placed in the client's case file. If it seems likely that the youth may later request placement in the Shelter, the date of the Brief Service, the youth's name and age, and a note referring staff to the Brief Service Log are placed in the Possible Admissions section of the Shelter Log.

Example Brief Service Entry

brief service

Date__4/25/93__ Telephone _x_ Drop-in ____ Other____ Case #_________

Program Contacted: __Shelter__ Referred by: __School counselor__
How learned about program: __friend__ Person making contact: __Kathy Black__
Relationship to Youth: __Mom__ Address or (County): __don't know__ Telephone #: __824-5555__
Name of Youth Involved:__Kevin Moore_________
Age__14__ Sex__M__ Race/Ethnic Background__don't know__

Presenting Problem & Help Requested: __M complaining Kevin's acting out @ home & having prob's & school. @ home K. picks on younger sib's. When M tries to intervene she & Kevin argue. 7 days ago argument escalated to point that K. shoved M. K. frequently leaves home w/out permission. He stays out past curfew. M thinks he's hanging out downtown w/some new friends who M doesn't like. K. having prob's @ Batchelor. He's in LD classes. He's disruptive in class. He gets into physical altercations w/the teacher & students. M very stressed & would like to discuss options in how to deal w/K. & if a X-out @ YS will help. The family not currently in counseling. K. on med's for wetting bed. No history of suicide.

Staff Analysis of Help Needed: __Set up an appt. w/YS counselor to asses situation in more detail. YS stay may be appropriate.

Agency Service Offered Yes_X_ No___ If yes, what:___Counseling appt. w/YS counselor.____________

Referral Made Yes___ No_X_ If yes, where:_______________________________

Follow-up Date ____________________________ Service provided:_________________________


Staff Member :__Ben Good_________

«Back To Top»

client log

Client Logs summarize the significant events and general behavior concerning each resident as noted in the OMs', AOMs' and Assistants' daily Log entries. The purpose of the Log is to provide a brief account of what happened to and with each resident during his or her placement for future reference in the event of a request for readmission or consultation with another agency.

We use the computer for Client Log. Staff will be trained regarding the directions for using the computer for the Client Log. There are also instructions saved on the computer, in the Word Perfect Program, "WP51", subdirectory, "CLNTLOG", file "INSTRUCT". There will be a computer file for each resident's Client Log. Every overnight OM types up an entry for each resident. The OM working the overnight immediately following an admission on an earlier shift should start a Client Log for the new resident. Upon exit, the overnight OM prints the resident's Client Log and places in his/her individual file.

Client Log Guidelines

1. Begin with: Resident's name, date of entry, and brief summary of admission or exit.
   • Summary of Admission - include the resident's age, referral source (parental, self, DFC, etc.), recidivist status, the presenting problem, i.e. what are the circumstances that led to the admission, and significant information beyond the presenting problem pertinent to the resident's admission to or stay at the Shelter, such as history of violence, involvement with drugs/alcohol, episodes of suicidal/homicaidal ideation or acting out, a medical condition, sexual, physical abuse or neglect, etc.
   • Summary of Exit - include time of exit, who resident exited with and where resident exited to.
2. Daily Entries:
• Date
• Daily tally
• General behavior - cooperation or uncooperation with the program, i.e. chores, study time, activity, interaction with residents and staff, etc.
• Temporary Exits for out of Shelter court, medical, or counseling appointments, visits, work etc.
• Visits in the Shelter
• Health/Medical Conditions - illness, injuries, etc. Medical Emergencies.
• Significant Behaviors - such as running away, smoking in the house, physical fight etc., designated as setback or mini-setback.
• Any significant behavior resulting in more than brief intervention by the OM or requiring consultation with the On-Call.
• When a resident is temporarily absent from the Shelter for the day due to an extended visit, a run away, etc., note that on the Log entry, e.g. "on run" or "on out of YS visit with M"
3. End With: Date and brief summary of exit. Also note any significant information regarding the residents last day in the Shelter, such as behavior problems, mood during he day, how resident cooperated with the program, etc.

«Back To Top»

Example Client Log

CLIENT LOG
PUGSLY ADDAMS
10-17-93	14 y.o. parental referral admitted @ 11:15pm. BPD trans; M met P. at YS. Pugsly suspended from school today after he was caught smoking on school grounds; 4th suspension this year - 2 for smoking, 1 for truancy & 1 for missing Sat. school. Mom & P. got into verbal argument that escalated to a shoving match once they got home. M threatened to call police & P. took off. Other problems - past physical fights b-tween M. & P., P. may be smoking pot, M stressed b/c live-in Bfr recently battered her & she's in process of kicking Bfr out. M. called YS & arranged to have P. admitted once BPD app.'ed. P. picked up @ Space Port. After intake, P. showered & went to bed.,
10-18-93	P. unhappy re: serving setback while suspended. Struggled to stay awake; eventually drew. Staff oriented & reviewed rules. Quickly catching on to program; taking initiative to interact w/residents. Some inappropriate conversation re: drugs & alcohol. Talked about how much he hates M's BFr. Intermittent spells of irritability & c/o headache. 6MP.

Using the Computer for the Client Log

Starting a Client Log for a Resident

1. Enter (Word Perfect) WP51:

-Turn on the computer: hard drive & screen
-Type in cd\WP51
-press>>>>Enter
-Type in WP
-press>>>>Enter

2. You should now be at a blank screen. The next step is to make the heading.

- in bold, capital letters, and very large font, type the heading, CLIENT LOG, at the center of the top of the page and underline the heading.

Follow these steps:
-get to the center>>>> Shift F6
-set capitals>>>> Caps Lock
-set underline>>>> F8
-set bold>>>> F6
-now type "CLIENT LOG"
-release capitals, underline & bold>>>> F8, F6, Caps Lock
-block the heading>>>> move cursor to the "C" in "CLIENT LOG" press F12 and then right arrow key, (or Home & right arrow key) until cursor just past the "g".
-change font to very large>>>> Ctrl F8, choose 1-Size,choose 6-Very Large
- Skip 1 line, start at the left margin, in bold, capital letters, type the resident's name

Follow these steps:
-set capitals>>>> Caps Lock
-set bold>>>> F6
-type in resident's name
-release capitals & bold>>>> F6, Caps Lock

3. Now you are ready to make an entry.

   - Skip 2 lines and type in the first entry of the client log.
   
   Follow these steps:
   -type date
   -set indent>>>> F4
   -type entry
   -indent is released anytime you press Enter (return)

4. Once you've finished the entry you need to save the file.

Follow these steps:
-save>>>> F7
-save document as "clntlog\(resident's name)"

«Back To Top»

Making an Entry in an Already-Existing Client Log

1. Enter (Word Perfect) WP51. See above directions.
2. Enter subdirectory for the client logs, "ClntLog".

Follow these steps:
-list files>>>> F5
-Enter
-Subdirectories and files are listed. Arrow down to ClntLog.
-Enter
-Enter
-Individual files are listed by the residents' names. Arrow down to the name of the resident you are going to log about.
-retrieve by pressing>>>> 1
*****Short Cut:
-list files>>>> F5
-type in "clntlog"
-Enter
this takes you to the subdirectory "ClntLog"; enter the individual file as directed above.

3. Make your entry. See above directions.
4. Save your entry.

   Follow these steps:
   -save>>>>F7
   -when it you get to the place where it asks you if you want to replace the file the correct answer is Y(yes).

5. Once your back to a blank screen press list files F5 twice and you'll be back to the subdirectory "ClntLog".

«Back To Top»

medications log

The Medications Log documents the dispensation of all over-the-counter and prescription medications to the residents. The Medications Log is kept near the OM desk. The Log consists of 2 sections. The first section consists of individual pages for each resident receiving medication. The second section consists of various excerpts from the Health Program, such as the Physicians' Orders for Over-the-Counter Medications, First Aid Supplies and First Aid Directives. Refer to the write up on the Medications Log in the section on Health and Hygiene.

cps log

The CPS Log documents the status of all incoming calls on the CPS line. The CPS Log is kept in the OM Office. There are directions for how to use the CPS Log in the front of that Log.

«Back To Top»

telephone log

The Telephone Log is kept in a folder in the OM office. The folder contains directions for placing long distance calls and Log sheets for all long distance calls placed from the OM desk. There are usually separate sheets for collect and direct calls. The OM must note on the correct sheet certain information about each call placed.

Example Telephone Log Entries

Direct Calls

Date	Time	Line	Number & Town	One-Call Card #	Company/Person Calling
9/8	3:10pm	506	Martinsville 317-342-1113	*4634	Morgan Co. P.O.
9/10	8:30am	507	Bedford 812-277-2044	*4634	Lawrence Co. DPW

*Not actual access code number.

Collect Calls

Date	Time	Line	Number & Town	One-Call Card #	Company/Person Calling
9/11	7:32pm	506	Bedford 812-279-2838	Collect	Bubba calling Mom
9/12	8:10pm	506	Linton 812-384-0066	Collect	Ellie May calling sis

«Back To Top»

resident log

The Resident Log is similar to a journal in which any resident can make an entry. The Resident Log is kept in the OM office. Residents must ask staff permission to use the Log. The residents should not be given the Resident Log during study or school time. There are guidelines concerning what kinds of things the residents can write about. These guidelines are written in the front of the Resident Log and are listed below. All residents and staff have access to the Resident Log. The information contained within is confidential.

If a resident abuses the privilege of writing in the Resident Log he she loses the privilege of writing in the Log for the rest of the resident's placement at the Shelter. The OM can consult with the Shelter Manager if there is question about this matter.

The Resident Log has been a useful outlet when residents are frustrated with the staff, the program, or need to vent their emotions regarding almost any topic, such as their family, school, what's going to happen to them, etc. The Resident Log has also provided a means for residents to say their good-byes. It is good to remind the residents at such times that they can use the Resident Log.

Resident Log Guidelines

1. Residents cannot use any profanities.
2. Residents cannot put other residents down.
3. Residents cannot talk about staff or residents in a sexual way.
4. Residents can write about - how the day is going, i.e. school, activities at the Shelter, etc., how they feel about the staff, how they feel about their living situation before coming to the Shelter, or where they may be placed after the Shelter.
5. Examples of Appropriate statements: "I hate Bob, the OM." "Joy, the AOM makes me so mad."
6. Examples of inappropriate statements: "Sue is a dog and she can kiss my butt". "Joe eats dog poop".

«Back To Top»

Communication

resident board

The Resident Board is in the OM office. The OM records certain information about each resident on the Board immediately after the resident is admitted to the Shelter. Staff should check the Resident Board at the beginning of each shift. The Resident Board concisely communicates important information about each resident, as illustrated by the following example and accompanying list.

Example Resident Board

1. Name Age	2. E.T.A. & D.O.E.	3. School(lunch,t-form)	4. Medication (allergies, health prob.)	5. Miscellaneous (contact restrictions, YS restrictions, i.e. hold, setback, etc.)
John 14y.o. *Setback	5:25pm 10/5/93	Tri-North $1.75	Allergic to bees Bee sting kit	-no contact with Betty Carter -Setback: 1st 24 up 10/9 3:30pm 2nd 24 up 10/10 3:30pm
Karen 13y.o. *Ran	9:12pm 10/7/93	Batchelor $2.OO	Yes see board	-no contact w/F, Burt Long
Bob 17y.o.	10:47am 10/8/93	Batchelor $2.OO	YSS	None -10/9 - loses next available activity

1. Resident's First Name & Age - *Also, short notation anytime a resident is placed on hold or setback, runs away or is on an extended temporary absence.
2. Date & Time of Admission
3. School - note the name of the Monroe County school the resident attends or resident attends Youth Shelter School. Do not note the name of out of a county school a resident attends. Indicate how resident gets lunch; if he/she takes money, note the $ amount. Note if the resident carries a truancy form or homework form. (See School section for more detailed information)
4. Medications - Yes resident takes or No resident does not take any prescribed medication. Details about administering medication are listed on the bulletin board by the OM desk. Brief note regarding any allergies or health problems.
5. Miscellaneous Information - note contact restrictions, special diets, special visits, etc.

«Back To Top»

monthly calendar

There is a dry erase board, monthly calendar in the OM office. All resident out of Shelter appointments and/or business for each month and school holidays are recorded on the calendar. Staff should check the Monthly Calendar at the beginning of each shift. The Calendar concisely communicates important information about each resident.

The Shelter Manager is responsible for recording school holidays on the calendar. The Case Manager is responsible for making sure necessary and accurate information concerning the resident(s) out of Shelter appointments/business is recorded on the calendar. Necessary information means that the following items are noted on the day(s) of the appointment/business:

1. resident's name
2. where resident is going i.e., probation dept., Dr.'s appt., crt., work schedule etc.
3. time of appt., and
4. who is providing transportation.

There is also a section on the Calendar to list appointments/business for the following month. The OM who works the overnight that begins on the first day of the month is responsible for making up the calendar for the new month, including transferring any appointments/business listed in the aforementioned section.

Example Calendar Note

3 Bob to crt. M trans 1pm Sue to Dr. Smith @ 2:30, we trans

4 1/2 day school out @ 11am Betty work 5-9pm bus there we pick up

John to MHC @ 1pm, F trans 5 Dave to crt @ 2:30pm, sheriff trans

«Back To Top»

client status sheet

The Client Status Sheet serves to document demographics and other personal information for each youth admitted to the Shelter. The Sheet is kept on a clip board in the OM office. The Sheet consists of a chart with individually labeled boxes. Each time a youth is admitted, the OM enters information on the Client Status Sheet. Also, when a youth is discharged the OM enters information and marks the youth off the Sheet.

staff mail boxes

Every Shelter staff member has a mailbox; sometimes more than one staff share a mailbox. Mailboxes are in the OM office. Staff should regularly check their mailboxes at the beginning of each shift for messages, instructions, etc. Staff should not keep items in their mailboxes that are must be kept locked. This includes medications, smoking materials, keys, pocket knives and money. It is suggested that staff not keep private or confidential material in their mailboxes because mail boxes are not "secure" and because some staff share mailboxes.

«Back To Top»

weekly staff meetings

All Shelter staff are required to attend a weekly staff meeting. OMs, AOMs, and the On-Call staff attend a 2 hours meeting. Volunteer, paid and intern Assistants attend a separate 1 hour meeting. Supervisors will inform staff of meeting times and places. Staff meetings are mandatory. Staff are allowed up to 6 absences from staff meeting during the calendar year. These absences do not include time off scheduled for vacation.

Meetings are vital in facilitating communication, planning and training among and for the staff. Meetings also provide staff a format in which they can share their ideas and concerns, ask questions and seek technical assistance. When needed we also use meetings to make group decisions. The typical format staff meeting: 1) discuss each of the residents; this include discussing each resident's care plan, behavior problems, special needs, etc., 2) depending on the resident group, discuss group dynamics and plan how to deal with issues, problems, etc., 3) discuss possible admissions, 4) discuss staff issues, 5) make announcements and discuss policy, procedure and training issues, and 5) review schedule changes. In service presentations are also scheduled approximately once a month, during staff meetings.

«Back To Top»