Documenting: Keeping a Binder

 

 

DOCUMENTING:

One of my goals for 2014 is to get organized, I've been going room to room clearing things out and preparing to get this all under control over here.  When my three boys first came I tried to prepare the best I could, but you don't really know what you don't know, LOL!  One of the areas that I totally could have done better in is organizing the massive amounts of paperwork, records, notes, and observations you have when dealing with foster care/adoption or children with medical/educational/mental health issues.  For the boys I have a HUGE Rubbermaid filled with papers, it is completely disorganized.  Today I am going to show you what I have been working on to get it all organized so I have a binder of documentation as it relates to the boys many needs and to make it easier to keep track of things going forward. 

Documentation is extremely important when you are dealing with children from trauma or children with mental health issues.  There are so many providers and professionals in and out of our lives that it is hard to keep track.  Every time we see someone new, I swear we leave with a new diagnosis or therapy to try or recommendation.  It doesn't matter if I tell them we have already tried X, Y, or Z for some reason they think I must not have tried it right or for long enough.  The unfortunate thing about mental illness is that it is not easily seen by a casual observer.  If my child had a cast on his leg and was taking awhile to walk down the aisle in the supermarket, no one would question that, people would try and help him or empathize with his situation.  When my child is screaming profanities and hitting me in the supermarket, the response in one of judgment, there is no help or empathy.  In the couple of incidences when we have had to take Matthew to the Emergency Room it has been hard to explain to the initial responders and later the hospital staff that we are here as a last resort, that we have tried all of our tools and strategies.  They see a cute little boy, but they don't see the years of trauma and abuse he has suffered.  They don't take you at your word when you try to explain the behaviors exhibited just mere minutes before.  We are not there because we are lazy parents who don't feel like dealing with our kid who is having a "tantrum".  This child that I am coming to you with has real issues, that are not his fault and not my fault.  He doesn't need coddled, I don't need a lecture, we need help.  By having all of your documentation in order and showing a history and pattern of behaviors you will have a much easier time getting the help you need and getting insurance coverage for some very expensive services that may be needed now or down the road.  Several parents I know have also had the unfortunate experience of having to deal with their local Child Protective Services or their children have been involved in the criminal system.  It is vital that you are able to protect your family from any accusations.  Having all of your documentation in one place certainly helps during these times and can help keep your responses and actions fact-based rather than emotion-based!

I decided a Binder for each child would be the best way to keep everything in one place and well organized. 


I've included individual links to most of my covers/forms, etc. as google docs so that you can modify them to meet your needs.  If you want just one file to download the entire binder, click here.





BINDER COVER:  You can get a copy of my Binder Cover here.  I choose to leave the child's name off of the front, that way if I need to bring the binder with me the name is not visible to anyone.  If you had more than one Binder you may want to put Initials or design a different cover to distinguish each child.

 

BACK OF BINDER:  I have a copy of this quote from Mother Teresa on the back outside cover of my binder.

 

Flash Drive:  Any time I receive paperwork, notes, emails, cards, etc.  I scan them into my computer and put a copy on the child's flash drive. By having your information in several places (Binder, Flash Drive and Computer file) you also prevent anything coming up "missing".  This is also a great way to keep copies of school work and crafts, just scan them onto the drive and you don't have to feel guilty about throwing away the weekly spelling test!  If you need to get the information to someone, you can always burn everything from the flash drive onto a CD that you can give them or email the specific documents they need.  I keep the Flash Drive and a few pens and post-its in a zipper pouch in the front of the binder. 

BASIC INFO SHEET:  This sheet goes in the front of the binder and contains any pertinent information such as, Name, Birthdate, Age, Grade, Height/Weight, Allergies, Medical Diagnosis.  I also put a current picture of the child on this sheet too.  If for some reason your child ever ran away or went missing this sheet could easily be given to the police.  I also have my child's fingerprint card and DNA samples on the back side of the plastic sleeve this sheet is in, you can get a free kit at http://www.pollyklaas.org/index.html.


CONTACT SHEET:  This sheet includes the names, addresses, phone numbers, fax numbers, and emails for anyone involved with the child.   Behind this sheet is one of those plastic baseball card collector sheets to place business cards in from various professionals involved with the child.  Always ask for a card or if they don't have one get their name and jot it down.   You never know when you will need to recall someone who had an interaction with the child.
 Case Workers
 Supervisors
 GAL/CASA
 Birth Parents
 Doctors
 Therapists
 Psychologist/Psychiatrists
 Counselors
 Evaluators
 Dentist
 Teachers
 Principal
 Former Placements
 Siblings and Extended Family
 Placements of siblings
 Hospitals
 Probation Department
 Residential Treatment Facilities
 In Patient Programs
 Out Patient Programs
 Partial Residential Treatment Facilities

CONTACT LOG:  You can get a copy of my Contact Log here.  Rather than tying to make all the information fit into columns, I've found it is easier for me to give myself as much space as needed to write notes or things I need to follow up on.  I will also insert written communication such as emails, cards, etc. in plastic page protectors.  I will still log these into the main Contact Log and then write "See Attached" in the notes section.  That way I can keep track of everything in chronological order. Get a copy of the cover sheet for this section here.

IMPORTANT PAPERS:  This section contains any important papers I need frequently, including copies of Adoption Decree, Birth Certificate, SS cards, Medical Cards. The other sheet I keep in here is a timeline of the child's life, including past placements and important events.  This can be very helpful when you are talking to various therapists and doctors, I find that having a visual of all the dates is helpful in getting a full picture of the child.  I can also add events to it as they come up or as new information is disclosed by those involved with the case.   Get a copy of the cover sheet for this section here.

CALENDAR: I have a monthly planner that I picked up at the dollar store in this section.  I find it is an easy way to keep track of appointments as well as jot down any behavior notes or incidents that I want to remember.  It is very thin so doesn't take up much space and it is bound, so I can store it each year much easier than having a bunch of loose monthly calendar pages.  I find it is helpful to develop some kind of rating system for the day (Red=Bad, Yellow= OK, Green =Good day OR a 1-5 scale), this way you can keep track of mood swings or patterns.  I keep the calendar indefinitely, this way you can compare patterns yearly as well.  For example, maybe you notice that every year around the date of the child's removal from birth parents things go downhill.  Once you get an idea about the patterns you can better anticipate and head off issues.

MEDICAL SECTION: If you have a child with significant medical issues you may find it best to have a whole binder divided by type of Doctor/Specialist.  For me,  I keep a summary sheet in the front with doctor/dentist information, how often and when they are supposed to see them, when the last appointment was and when the next one will be.  If the child has medical issues that require medications (not psych related)  I keep a separate sheet listing current medications, dosage, directions, who prescribed them as well as a medication history sheet showing past medications and notes on any side effects or how well they worked.   I have a medication log to document that I have given any medications.  I then just keep all medical documents by date, if something is important and I will need to find it quickly or often I will put a post-it note on it that sticks out a little from the binder.  In the back of this section I keep Incident Reports which I fill out if there are any bumps or bruises that I want to document.  Get the cover sheet for this section here.

 

EDUCATION SECTION: I keep a sheet of important information up front, School contact info, teacher name, grade, room #, schedule including "specials" (for example 'Gym Day' so we bring sneakers), school calendar, IEP dates.  Next is a copy of the current IEP and Evaluation in page protectors as well as a copy of the most current Procedural Safeguards for the state.  Afterwards all important documents are hole punched and put in reverse chronological order, with the most recent up front.  If a child receives early intervention I keep that paperwork in this section rather than medical section. Get the cover sheet for this section here.

PSYCHIATRIC SECTION: In this section I keep a summary sheet listing all current therapist/counselors with contact information as well as current medications.  I keep a separate sheet listing current medications, dosage, directions, who prescribed them as well as a medication history sheet showing past medications and notes on any side effects or how well they worked.  I keep the pamphlet that comes with the child's medication from the pharmacy and place a copy in the binder, it is a good summary of the possible side effects as well as useful for medical history when you are trying to find the right combination/dosage of medications.  I use the back to write detailed notes and observations on the medication.  I usually keep a few copies of their current medication sheet so I can hand it out when asked what medications the child is on ( I also include any Over the Counter medications or vitamins that are given regularly).  I have a medication log to document that I have given the medications.  I then just keep all medical documents by date, if something is important and I will need to find it quickly or often I will put a post-it note on it that sticks out a little from the binder.   I then have a copy of any current treatment plan in a page protector with all past treatment plans or therapy information hole punched in reverse chronological order.  This would include psychiatric evaluations, intake/progress/discharge records from psychiatric emergency room visits, inpatient/outpatient treatment centers, residential facilities as well.

SAFETY PLAN SECTION: In this section I keep a copy of our family's current safety plan in plastic page protector.  Any past safety plans are hole punched and placed in reverse chronological order behind the current one as well as any notes as to why it needed changed.  A safety plan is extremely important for a family to have BEFORE you are caught in the middle of a crisis.  It is very hard to think clearly when all hell is breaking loose and you are trying to keep everyone safe.  See my post on creating a family safety plan here.  Click here to see my post on creating safety plans.

BEHAVIOR SECTION:  This section will vary depending on what behaviors need to be addressed in each child.  I keep a Monthly Calendar at the front of the binder where I can jot down things, but keep note pages where more detailed summaries can be placed here.  Its often easier to make some quick notes on the calendar so I don't forget and then come back a the end of the week and put in some more detailed explanations here.  If we are using a specific behavior sheet or reward program I will include those here. I have an incident report form that I use to document events that I feel are bigger or more serious than the minor daily issues.   Get a copy of this sections cover sheet here.

COURT RECORDS: If your child is involved in any court actions you can keep a summary sheet of any court info you may have, court house address and contact information, judge assigned, attorney information, case number, important dates.   The rest of the Court paperwork gets organized by date.  I will also include a note page with a summary of what happened at a court date and include it accordingly. This section can also be used for any Police reports you may have, for example if Police had to be called to help get an unsafe child to the hospital. Get the cover sheet for this section here.

ARTICLES/DIAGNOSIS EXPLANATIONS: I keep a copy of important articles as well as summarized versions of the child's diagnosis in this section, along with a few extra copies.  These are great to hand out to people who are not knowledgeable about the diagnosis or who genuinely show an interest in learning more. I also keep a copy of the side effect sheets for any medication they are on.  Get the cover sheet for this section here.