CDDN key terms

A process that builds a service plan around the individual's own goals, preferences, and chosen life outcomes, using the person's own words and the people they trust rather than fitting the person to available services.

A written document that states a person's assessed needs, goals, and the specific supports and services to be delivered, including who is responsible and when progress will be reviewed.

A measurable statement of what a person will do, under what conditions, and to what level of performance, written so that anyone reading the record can tell whether progress occurred.

Measurements of a behavior or skill taken before an intervention begins, used to establish the starting point against which later progress is compared.

A group of professionals from different disciplines, together with the person served and chosen family or advocates, who jointly assess needs, plan services, and review progress toward agreed outcomes.

Skills used to run a meeting so that the person's voice is heard, the agenda is followed, disagreements are addressed respectfully, and decisions and assignments are recorded before people leave.

The family members, friends, staff, and community members a person chooses to rely on for practical help, advice, and relationships, often invited to contribute to planning.

The right and capacity of a person to make choices about their own life, including where to live, work, and spend time, with support offered only as needed rather than control substituted for choice.

The principle that services, settings, and interventions should limit a person's freedom no more than necessary to meet a legitimate safety or treatment need.

Agreement given by a person, or an authorized representative, after receiving understandable information about the proposed action, its risks, benefits, and alternatives, without coercion.

A legal arrangement in which a court grants one person authority to make specified decisions for another who is found unable to do so, limited to the powers the court actually orders.

Acting to protect and promote a person's rights, wishes, and access to services, including speaking up with them or on their behalf when their voice is not being heard.

A documented process by which a person or representative can formally complain about services, receive a timely response, and appeal an unfavorable decision without fear of retaliation.

Procedural protections that must be followed before a service is denied, reduced, or a right is restricted, including notice, a chance to be heard, and an appeal.

The duty to protect personal health and service information from unauthorized disclosure, sharing it only with those who need it for a legitimate purpose or as the law permits.

Individually identifiable information about a person's health, care, or payment for care that is created or held by a covered provider and is subject to privacy protections.

A signed, dated authorization that names what information may be shared, with whom, for what purpose, and for how long, and that the person may revoke.

The rule that only the amount of protected information needed to accomplish a specific purpose should be used, disclosed, or requested, rather than the entire record.

The requirement to record care, observations, and medication events within the timeframe set by policy, so that the record reflects what happened while memory is still accurate.

A note written after the fact to record an earlier event, clearly labeled with the actual date and time of the event and the date the note was written.

Recording observable facts, direct quotes, and measured data rather than opinions, labels, or conclusions, so the record can be relied on by others.

A factual record of an unusual event such as injury, medication error, elopement, or allegation of abuse, completed promptly and routed for review rather than filed in the service record.

The legal duty of certain workers to report suspected abuse, neglect, or exploitation of a vulnerable adult or child to the designated authority within the required timeframe.

A structured review that looks past the immediate error to identify the underlying system conditions that allowed it, then assigns changes with owners and deadlines.

A written plan that names a measurable quality problem, the actions to correct it, the person responsible, and the date by which improvement will be re-measured.

A specific, countable measure used to track whether services meet a standard, such as the percentage of plans reviewed on time or of medication passes without error.

A systematic review of records, practices, and site conditions against defined standards, producing findings and corrective actions rather than a pass or fail judgment alone.

The official record listing each prescribed medication, dose, route, time, and the initials of the person who administered or withheld each dose, with reasons for omissions.

The checks performed before giving any medication: right person, right medication, right dose, right route, and right time, with documentation as the confirming step.

Any preventable event that may cause or lead to inappropriate medication use or harm, including wrong drug, dose, route, time, omission, or unauthorized administration.

A medication ordered to be given only when a specified condition occurs, with the dose, indication, and required follow-up documented each time it is administered.

The process of comparing a person's current medication list with new orders and discharge instructions to catch duplications, omissions, and interactions before they cause harm.

An approach that reduces challenging behavior by changing environments and teaching replacement skills, rather than relying primarily on consequences or restriction.

A process of gathering information to determine what a behavior achieves for a person, such as attention, escape, or sensory input, so that support addresses the actual function.

A written plan describing prevention strategies, replacement skills to teach, and responses to challenging behavior, implemented consistently across staff and reviewed with data.

Any manual, mechanical, or chemical method that restricts a person's movement or behavior and is used only under specific authorization, time limits, monitoring, and reporting requirements.

The routine, defined recording of observable behavior or skill performance using an agreed method and schedule, so that progress can be judged against baseline.

Organizing and linking a person to needed services across providers, including referrals, eligibility follow-up, and monitoring that services are actually delivered and not duplicated.

Advance preparation for a change in setting, provider, school, or life stage, covering skills, records, medications, and supports so continuity is maintained.

Staff education that requires demonstrated performance of a skill, not just attendance or a passing quiz, before the worker is considered qualified to perform it independently.

A teaching and verification method in which the learner performs a procedure back to the instructor, who observes and corrects until the steps are done correctly.

Required orientation and instruction completed before a new employee works independently with consumers, covering rights, safety, reporting duties, and core job skills.

Ongoing education provided during employment to maintain and update skills, meet annual hour requirements, and address needs identified through supervision or quality review.

Regular, documented oversight in which a supervisor observes performance, gives specific feedback, addresses problems early, and confirms that required competencies are maintained.

Assigning a task to another worker while retaining accountability for it, permissible only when the task is within the worker's training, legal scope, and verified competence.

A stepwise response to performance or conduct problems, from coaching and written warning to stronger measures, documented at each step and matched to the seriousness of the issue.

A situation in which a staff member's personal, financial, or family interest could improperly influence a service decision, which must be disclosed and removed from the decision.

Teaching people served about their rights, their own health conditions, medications, and how to navigate services, delivered in plain language and checked for understanding.

A check for understanding in which the learner explains or demonstrates the information in their own words, and the teacher re-teaches anything that was not clear.

Writing and speaking that uses short sentences, common words, and clear structure so the intended audience can find, understand, and act on the information the first time.

The official written record of a meeting's decisions, actions, responsible parties, and deadlines, circulated for correction and retained as evidence of the planning process.