The Power of Documentation in Direct Support

By Keegan Wassam, Executive Director, and Michelle Van Vickle, House Manager – Lasting Impressions MO LLC

At Lasting Impressions, our mission has always been to provide the highest level of support for the individuals we serve — not just through the care we give, but through the insight, empathy, and dedication of our incredible team of Direct Support Professionals (DSPs). Our DSPs are the eyes, ears, and advocates for our clients each and every day, and the work they do often goes far beyond what meets the eye.

One of our House Managers, Michelle Van Vickle, recently shared a powerful message with her team about the importance of detailed documentation in our work. Her words perfectly capture why this practice is not just an administrative task, but a vital tool for improving quality of life, tailoring support, and advocating effectively for each person we serve.

I’m honored to share Michelle’s message with you here — a reminder to all of us that what we write down today can directly shape the support and opportunities our clients receive tomorrow.

Why Detailed Documentation Matters

"As a DSP, we are our clients' first and strongest advocates." – Michelle Van Vickle

The purpose of thorough documentation is to help our DSP support team see and understand our clients on a personal level. Our team strives to be involved and design the best environment for each individual as needed. However, our DSPs are the actual day-to-day. Admin depends on each piece of documentation from us to meet our clients' needs as individually as possible. As DSPs, we see the struggles personally, and we see the growth as they adapt and overcome daily challenges. If documentation is thorough and details the emotional, physical, and social interaction of the clients, our team can evaluate the effectiveness of the situation or situations and determine what tools could be implemented to improve either their environment or interactions.

Facts Over Opinions

It is essential to make statements on each interaction and only share statements of fact, not opinions.

Instead of writing: "I feel like Daniel would benefit from having a ramp on his porch." Consider documenting: "Every time David gets to the stairs he is hesitant, waves his hands rapidly, and tries to use the back entry without stairs." This allows the team to see a pattern and determine whether an intervention may be necessary.

Patterns Reveal Solutions

Our admin team is not capable of being in every home every day. As a DSP, we are our clients' first and strongest advocates. We should all have the mindset of:

• What emotions or actions did the client display today?

• How do they physically navigate their situation?

• Did they argue and refuse to take a shower? Do they do this frequently?

Documenting these details helps identify patterns. For example, if a client refuses Monday morning showers but cooperates on other days, that might signal a simple schedule change as a solution.

"If You Don’t Document It, It Didn’t Happen"

Some DSPs have expressed that they have spoken about a need but feel it hasn’t been addressed. The truth is, without written documentation, requests and observations can be missed or forgotten.

If you don't document it, it didn't happen.

Verbal requests or conversations alone do not validate a need to insurance or guardians. Documentation does.

Documentation Drives Change

Adaptive equipment and care costs money, and funding sources require proof of need. For example, if no documentation shows that Michelle struggles daily to get out of her recliner, insurance won’t cover an electric chair. But if every DSP documents her struggles, the team can build a strong case for intervention.

Our documentation validates why our clients benefit from our services and why continued support is essential to their growth and quality of life.

Your Role as Observer and Advocate

Documentation allows our DSP support team to see how clients live and perform daily tasks. As a DSP, you are the observer and voice for your individual. Your observations — when detailed and consistent — allow the team to determine and validate what will most benefit them personally.

When you document daily, you may find you no longer have to ask for certain changes — the patterns will speak for themselves. And while documentation is powerful, DSPs should still remain the frontline advocates for any potential improvements in quality of life.

With utmost sincerity,

Michelle Van Vickle

House Manager

DSP and Team Advocate (always)