Risk Ma nag ement Write Right! Documenting Camp Incidents Camp professionals generate many documents. While some documents aren’t retained very long, others are preserved because they contain critical information. It’s these critical records that deserve attention; do they contain sufficient information presented in an appropriate manner? In other words, how does one “write right”? Interestingly, literature from the camp community is thick with information about what incidents to document (Coleman and Coleman, 2009; Coutellier, 2008; Ball and Ball, 2009) but light on comment about the characteristics of good documentation. That information tends to come from risk management literature and is the subject of this column. General guidelines will be presented. Individual camp professionals are reminded to consult their legal expert regarding the application of this information to their camp. General Documentation Guidelines Appropriate documentation is more than just “filling in the blanks” of an incident report or health record. According to various sources (Harper College, 2013; Hendren, 2011; Richards-Gustafson, 2013; Treder, 2013), these broad practices are standard: A. Document in a timely manner (as soon as possible after the event) using the appropriate form or per the direction of the individual who oversees the documentation process. B. If writing the information by hand, use a pen with black or dark blue ink — and write so others can read what has been written! If using a keyboard, initial each page by hand and then place one’s full signature at the end of the document. C. Use the legal name of individuals. Insert date(s) and time(s) as relevant to what is being written. Consider adding camp session for campers or job title for staff. D. Describe the context/setting: When and where did this happen? List factors that may be unique to the environment. Describe any prior interactions experienced with the individual(s). E. Objectively describe what happened in chronological order; stick to the facts. Record details in objective terms. Describe what was seen and heard by the person doing the documentation; distinguish between personal knowledge and what one learned from others (e.g., “Sally told me that . . .”). Include behavior (actions) and what was said (use quotes); describe tone of voice and observed body language. Include how often something happened (frequency) and how long it lasted (duration). F. Be accurate, concise, and clear. Double-check names, spellings, dates, and times. Be grammatically correct and use appropriate punctuation. Skimping on these elements risks being misunderstood or introducing doubt as to what was meant. G. Name others who were involved as witnesses (those who actually saw what happened) and/or to whom the incident was reported. H. AVOID opinions and blame statements. I. Date and sign (do not merely type) the documented content when it’s completed. Note Underlying Assumptions Reading the information just described may trigger other questions, especially regarding the assumptions upon which documentation practices are based. For example, most camp staff are emerging professionals who do not routinely document incidents. As a result, assume that they will need coaching about how to document. Provide that coaching during orientation but also at the time of an incident. Taking a moment to review the guidelines before someone — camper or staff member — documents the incident from 16 CAMPING magazine • March/April 2014 his or her perspective should help create a better document. Also consider how long documentation might be kept. This decision not only affects where one might store critical records, but also colors the decision as to what medium is used for critical documentation. Paper remains just about the only surefire archive option in today’s world. Computer systems and devices have changed so quickly that it’s difficult to tell if today’s option will be retrievable in tomorrow’s world. Another underlying assumption is that documentation reflects the perception of the writer. An eighteen-year-old, brand-new camp counselor would be held to a different expectation than an experienced camp professional. There is allowance for recognizing that documentation expectation varies given individual experience and age. Documentation Done by Health Center Staff It’s easy to forget that health center staff document many interactions with campers and staff. Indeed, some camps continued on page 18 Li nda Eb ner Erc eg, RN, MS , PHN
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