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Overview

Service Records document that services were provided to a specific member, within a specific group, on a specific day. They include all critical time tracking and notes completed by staff to ensure daily compliance. They are one of the most fundamental components to Kibu and your compliance.

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Key Components

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Member Information

  • Individual member details
  • Group association
  • Assigned staff members
  • Attendance status (Present/Absent)

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Time Tracking

When enabled, tracks:
  • Member arrival time
  • Departure time
  • Total service duration
  • can easily be exported to reports for billing-related needs
Time tracking can be essential for billing accuracy and compliance requirements. Make sure this feature is enabled if your organization requires it.

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Documentation Fields

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Required Notes

  • Customizable fields based on your organization’s compliance requirements
  • Structured documentation sections
  • Progress notes
  • Behavioral observations

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Life Plan Goals

  • Links directly to member’s Life Plan Goals
  • DSPs track daily progress on assigned goals during their shift
  • Each goal appears with its specific tracking questions and response options
  • Goals can be marked as completed, attempted, or not applicable for the day
  • Responses contribute to the point-based tracking system for measuring long-term success
Use quick notes to document specific examples of goal progress throughout the day - this helps create a more detailed record of the member’s achievements.

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Starting a service record

To start a service record, navigate to the group where the member is receiving services. From there, you can create a new service record for that individual at the beginning of each day, If a member is marked as present a record automatically gets created and is free to be edited. After staff members are assigned to individuals and service records are created, these records appear on each DSP’s home page as an incomplete service record. As DSPs complete their daily documentation, the records are removed from view. The ultimate goal is to have all records completed by the end of the day, resulting in a clear home page and 100% compliance .

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Timeline Feature

The left-hand timeline provides a structured view of the member’s day:

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Quick Notes

  • Quick notes appear in the timeline as staff enter them throughout the day
  • Each note is automatically timestamped and displayed chronologically
  • Provides real-time documentation of member activities and events
  • Creates a natural flow of the day’s activities as they happen allowing for easy record completion at the end of the day
Encourage staff to add quick notes throughout their shift to maintain an accurate timeline of activities and events.

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Magic Pen AI Assistant

Our innovative Magic Pen feature streamlines documentation by:
  • Reading member quick notes for the day automatically
  • Analyzing the data
  • Auto-populating relevant service record fields in documentation and life plan goal sections
  • Saving staff hours of manual data entry

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How Magic Pen Works

  1. Staff enters quick notes throughout the day
  2. Click the Magic Pen button when ready
  3. AI analyzes the quick notes
  4. Service record fields are automatically populated
  5. Staff reviews and adjusts as needed
Always review AI-generated content for accuracy before finalizing service records.

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Completing Service Records

To complete a service record:
  1. Open the service record from your dashboard or group view
  2. Fill out all required fields and necessary documentation
    • Use Magic Pen for timesaving
  3. Review the information for accuracy
  4. Click “Sign & Approve” to finalize the record
You can save partially completed records and return to them later in the day. The record will remain in your incomplete list until signed.
Service records can be modified even after being signed if needed:
  • Access the signed record from the group’s documentation history
  • Make necessary changes or additions
  • Re-sign the record to save modifications
  • All changes are tracked in the record’s audit history
Ensure all documentation is accurate and complete before signing. While records can be modified later, maintaining accurate documentation at the time of service is a best practice for compliance.

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Service Record Information

  • Member details
  • Staff assignments
  • Required documentation fields
  • Active life plan goals

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Best Practices

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Documentation Tips

  • Update records in real-time when possible
  • Use quick notes for immediate documentation
  • Review Magic Pen suggestions carefully
  • Ensure all required fields are completed
  • Document goal progress accurately

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Compliance Considerations

  • Complete all required fields
  • Document according to organizational standards
  • Maintain consistent documentation practices
  • Review records before finalizing

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Time-Saving Features

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Quick Notes

  • Rapid activity documentation
  • Real-time timeline updates
  • Simplified entry process
  • Activity tracking efficiency

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Magic Pen Benefits

  • Reduced manual data entry
  • Consistent documentation format
  • Time-saving automation
  • Improved accuracy

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Training Staff

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Key Points to Cover

  1. Proper documentation practices
  2. Quick notes utilization
  3. Magic Pen utilization and proper review as AI can be wrong
  4. Compliance requirements

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Support and Resources

Need help with service records?
Regular training and support ensure your team makes the most of Kibu’s service record features while maintaining compliance standards.