CDDN cheat sheet

Competency-based training requires demonstrated performance, not attendance: a skills checklist signed by an observer documents that the trainee performed each task correctly before independent practice.

Training records must capture date, trainer name and credentials, content, method (demonstration, return demonstration, classroom), and outcome; records are retained per agency policy and state licensing timelines.

Annual retraining is typically required for CPR/first aid, medication administration, fire safety, infection control, and abuse/neglect reporting; other skills recur on a schedule set by policy or regulation.

Adult learning principle: retention improves with hands-on return demonstration and spaced practice; single-session lecture alone is insufficient for psychomotor skills.

Orientation must cover the individual's ISP/IEP goals, rights, communication needs, behavior support plans, and emergency procedures before the staff member works alone.

In-service training hours are usually specified per year by the licensing body; track hours by category (mandatory vs. elective) so audits reconcile quickly.

Trainer qualifications must be documented; a trainer teaching medication administration often needs current licensure plus agency-approved trainer certification.

When a new procedure or equipment is introduced, training must precede use; a signed competency dated before the first use is the audit-proof record.

Cross-training and refresher training should be triggered by incident trends, new diagnoses, or changes in the individual's plan, and the trigger documented in the training file.

Provide support in the order of the individual's plan: personal hygiene, meals, mobility, toileting, and positioning follow the written schedule and any physician orders.

Handwashing with soap and water for at least 20 seconds is required before and after direct contact, after toileting assistance, and before food handling; alcohol-based sanitizer is not a substitute when hands are visibly soiled.

Standard precautions apply to all individuals regardless of diagnosis: gloves for blood, body fluids, mucous membranes, and non-intact skin; change gloves between tasks and between individuals.

Positioning and repositioning schedules (commonly every 2 hours for at-risk individuals) are documented with time and position to prevent pressure injury.

Report changes in condition - new confusion, refusal to eat, skin breakdown, falls, or behavior change - to the supervisor and document the time reported.

Mealtime support includes prescribed textures and thickened liquids; never change a diet texture or fluid consistency without a clinician's order.

Assistive devices (gait belts, transfer boards, lifts) are used per training; a two-person transfer requires both staff present before starting.

Restraint or restrictive intervention is never used for convenience or discipline; only per an approved plan, with monitoring and release documentation.

Documentation in direct care is contemporaneous: record what was done, when, and the individual's response, not opinions or speculation.

Supervision frequency should be defined in policy (e.g., weekly or biweekly) and evidenced by dated notes covering observed performance, feedback given, and follow-up items.

Direct observation of a staff member performing a skill is the strongest evidence of competency; pair observation with a written competency checklist.

Delegation requires three elements: the delegate has the training, the task is within the delegate's permitted scope, and the supervisor retains accountability for the outcome.

Performance concerns follow a progressive process: verbal coaching, written improvement plan with measurable goals and timeline, then formal discipline per HR policy.

Supervisors must ensure staff do not work beyond their scope of practice; verify licensure/certification status and expiration dates on a tracking log.

Incident review is a supervisory function: gather facts, verify documentation, identify contributing system factors, and document corrective actions and dates.

Confidentiality applies to supervision records; performance discussions occur privately and are stored in the personnel file, not the individual's record.

Staffing ratios and coverage must meet the individual's plan and regulation; document substitutions and the qualifications of replacement staff.

Assessment is ongoing and multi-source: interview, direct observation, records review, and input from the individual, family, and team members.

Functional assessment describes what the person can do and needs support with (ADLs, IADLs, communication, mobility) rather than assigning a diagnosis-based label.

Baseline data must be measurable and dated; a behavior or skill goal needs a defined metric (frequency, duration, latency, percentage of opportunities) before intervention begins.

Risk screening covers falls, choking/aspiration, skin breakdown, seizures, elopement, medication side effects, and abuse/neglect indicators.

Informed consent for assessment and release of information must be obtained and documented before sharing records with outside parties.

Standardized tools are used as designed: same instructions, same scoring, same environment; deviations are noted because they affect comparability.

Reassessment intervals are set by regulation or plan (commonly annual, plus after significant change); a significant change triggers an earlier reassessment.

Assessment findings drive the plan: each identified need should map to a goal or a service, and unmet needs are documented with rationale.

An ISP/IEP is person-centered: goals reflect the individual's stated preferences and are written in observable, measurable terms with a target date.

Each goal includes baseline, criteria for mastery, method of measurement, and who is responsible, so progress can be verified at review.

IEPs require present levels of academic and functional performance, measurable annual goals, and a statement of special education and related services and accommodations.

The team must include the individual (as appropriate), family/guardian, and required professionals; attendance and excused-absence documentation are part of the record.

Services are delivered in the least restrictive setting consistent with the plan; placement decisions follow goal development, not precede it.

Plan amendments require the same team process as the original plan unless a documented expedited procedure applies; verbal changes are confirmed in writing.

Review at least annually and whenever the individual's needs change significantly; progress reports are issued on the schedule the plan specifies.

Transition planning begins by the age specified in regulation (age 16 under IDEA in the U.S.) and addresses postsecondary goals, services, and linkages.

The plan is a working document: direct-care staff must have access to current goals and data sheets, and revisions are communicated to all implementers.

Teach self-advocacy skills explicitly: identifying a need, requesting help, and knowing how to file a grievance, with practice and feedback.

Materials should match the person's reading level, language, and communication mode; plain language and visual supports increase comprehension.

Teach-back confirms learning: ask the person to explain or demonstrate the skill in their own words rather than asking 'do you understand?'

Rights education covers dignity, privacy, freedom from abuse and restraint, choice, and access to records; document the date rights were explained.

Health education topics (medication purpose and side effects, symptom reporting, hygiene, nutrition) are taught in small, concrete steps with repetition.

Consent to teach and to share information is documented; refusal is respected and re-offered later rather than overridden.

Skill mastery is measured by observed performance in the real setting, not by quiz scores alone; record the date independence was achieved.

Peer support and self-advocacy groups are legitimate teaching modalities; document participation and the goals addressed.

Care coordination maintains a single current plan of record; all providers receive the same version and changes are distributed with a date.

Referrals are tracked with referral date, receiving provider, reason, and outcome; unclosed referrals are followed up on a defined schedule.

Eligibility and funding rules determine which services can be authorized; coordinators verify authorization before service delivery begins.

Transitions (hospital to home, school to adult services, provider change) require a written transition plan with responsible parties and timelines.

Coordination includes identifying gaps and duplication: map each need to exactly one responsible provider where possible.

Release of information must specify recipient, purpose, and expiration; coordination cannot proceed on a blanket consent that does not cover the exchange.

Document contacts with date, time, participants, decisions, and next steps; case notes should let another coordinator continue without re-interviewing the individual.

Conflict resolution among providers escalates through defined channels with the individual's preferences as the deciding factor when safe.

QA uses predefined indicators with thresholds; a finding is a measured deviation from the threshold, not an opinion.

Data sources include incident reports, medication error logs, plan progress data, satisfaction surveys, and record audits; sampling method is documented.

Root cause analysis asks why the event occurred and identifies system factors (staffing, training, communication, environment) rather than blaming an individual.

Corrective action plans state the action, responsible person, due date, and how effectiveness will be verified; re-audit confirms closure.

Trend analysis compares rates over time and across units; a single incident is reviewed, a pattern triggers system change.

Confidentiality protects QA deliberations under applicable peer-review or quality-improvement protections where law provides them.

Consumer and family feedback is a required QA input; document how input was solicited and what changed as a result.

Audit tools should mirror the documentation standards staff are trained on, so audit findings and training content stay aligned.

Record contemporaneously or as soon as possible; late entries are labeled as late with the actual date and time of entry.

Corrections are made with a single line through the error, the correction, initials, and date; never erase, use correction fluid, or overwrite.

Each entry includes date, time, service provided, the individual's response, and the signature with title/credential of the author.

Objective language only: describe observable behavior and direct quotes; avoid labels such as 'manipulative' or 'difficult'.

Records are legal documents and may be subpoenaed; write as though the individual and family will read the entry.

Confidentiality rules govern storage, access, and transmission; share only the minimum necessary information with authorized parties.

Retention periods are set by regulation and payer contracts; know the required retention for minors and for incident-related records.

Medication and treatment records require the time given, dose, route, and signature; refusals and omissions are documented with the reason and who was notified.

Flow sheets and checklists are part of the record; a blank field is ambiguous, so mark 'not applicable' or 'refused' rather than leaving it empty.

The rights of medication administration: right individual, right medication, right dose, right route, right time, right documentation, and right to refuse.

Verify the order against the label and the individual's identifier before administration; two identifiers are used, not room or bed number.

Medication errors (wrong dose, time, route, omission, unauthorized drug) are reported immediately to the supervisor and prescriber per policy, and an incident report is completed.

Never administer a medication prepared by another person or with an illegible or incomplete label; clarify the order first.

PRN medications require a documented indication, parameters for use, and evaluation of effect after administration.

Controlled substances require count verification at shift change with two signatures and documentation of any discrepancy.

Treatments and procedures follow the written order and the trained technique; aseptic technique and hand hygiene precede invasive procedures.

Refusal is documented with the reason, education provided, and notification of the prescriber; refusal is not overridden without an order.

Medication administration training and competency must be current; the record shows the date competency was verified and by whom.

Core rights include dignity, privacy, freedom from abuse and neglect, freedom from unnecessary restraint, choice, and access to one's own records.

Informed consent requires capacity, disclosure of risks and alternatives, voluntariness, and documentation; consent can be withdrawn at any time.

Grievance procedures must be explained in accessible language, with a known contact, timelines, and protection from retaliation.

Mandatory reporting: suspected abuse, neglect, or exploitation is reported to the designated authority within the required timeframe, and internal notification does not replace the external report.

Least restrictive alternative: any limitation on rights must be justified, time-limited, reviewed by the team, and documented.

Advocacy includes supporting the person to speak for themselves; substitute decision-making is used only when authorized and only to the extent necessary.

Confidentiality rights extend to conversations, mail, phone calls, and visitors; restrictions require documented justification.

Guardianship and power of attorney documents define decision authority; staff verify the scope of authority rather than assuming it.

The team includes the individual, family/guardian as appropriate, and required disciplines (nursing, therapy, education, coordination, direct support) per plan and regulation.

An agenda distributed in advance and minutes recorded after are the two records that make a meeting auditable.

Minutes capture attendees and roles, data reviewed, decisions made, dissent noted, action items with owners and due dates, and the next review date.

Quorum and participation requirements are set by regulation; excused absences and input submitted in writing are documented.

Decisions are made by consensus where possible; when the team cannot agree, the documented escalation or dispute-resolution process applies.

Person-centered meetings begin with the individual's goals and preferences before reviewing deficits or data.

Confidentiality applies in meetings: discuss only information necessary for the team's purpose and confirm who is authorized to attend.

Follow-up is verified at the next meeting: action items are reviewed for completion, and incomplete items are reassigned with a new date.