Compliance Quick Reference

DDD Documentation Standards

• Timeliness: Document within 1 hour of care/service
• Accuracy: Factual, objective, no opinions
• Completeness: No blank fields — write "none" or "not applicable"
• Legibility: Typed entries only (no handwriting)
• Authentication: Initials only — never share passwords

Prohibited Practices

• ❌ Pre-charting (documenting before care)
• ❌ Copy/paste documentation (must be individualized)
• ❌ Documenting for another staff member
• ❌ Using correction fluid or deleting entries
• ❌ Sharing login credentials
• ❌ Accessing records without need-to-know

HIPAA Compliance

• ✅ Log out when leaving your computer
• ✅ Never discuss members in public areas
• ✅ Use only work email for member information
• ✅ Report suspected breaches immediately
• ✅ Secure mobile devices with passwords