Recommend continuing the current intervention and short term goals. consumer and attempt to utilize community and natural supports. Monthly progress notes document consumer progress relative to goals identified in the Individualized Service Plan, and indicates where treatment goals have not yet been achieved. Problems: lack of time, lack of understanding of legal issues, clinical use/value, training and support, agency policies and guidelines, no consistency among practitioners, auditor Peer Counselors are responsible for the implementation of peer support services. Case Notes / Client Notes / Progress Notes ! 90805 (psychotherapy w. E/M services) Time spent counseling and coordinating care: 45 -50 min The term you use might be different from this, but the Don’t make it personal. When writing a performance review, it helps to take a look at the issue(s) you’ve included and ensure that they apply to actions and behaviour of the employee rather than the personal attributes of said employee. DAILY SERVICES/SUPPORTS DESCRIPTIONS, COMMENTS, AND PROGRESS NOTES: Day of Week & Date ↓ DESCRIPTIONS, COMMENTS, AND PROGRESS NOTES ↓ Anytime the DSW makes either a description, comment or progress note entry, the day of the week should be noted with the particular date. Results of these reviews should be documented in progress notes to reflect both the person’s progress and verification of coaching services. It has been rewritten objectively, more concisely, in the active voice and only necessary information included. AOD, PG and mental health and social services vary in approach to writing case notes ! At the end of this session you will understand more about progress notes. 2. Examples of Progress Notes are available at Personal Support Worker Resources Progress Notes are a legal document not an opportunity to be creative and write an interesting story. Feedback is about actions and behaviour, not the person. All timesheets include an area for service documentation that describes both the supports and progress toward the goal, on the back of the timesheet. Following is an example of a progress note adapted from Community Circles, Inc. No progress in reaching these goals or resolving problems was apparent today. Below is an example of a note which is too long. It is felt that more time is needed for the interven tion to work. Note We use the term “progress notes” to refer to the documents created by support workers at the end of a shift. If the Progress Note does not reflect an authorized service being delivered the Case Management Entity may need to contact the individual or their representative to do monitoring ensuring that the needs are being met. Your team will also have some draft exemplars and guidelines that you can use in the future. Progress Note is signed and dated Date of service, time spent, and location Strengths observed. Documentation of any significant life events (successes and/or barriers). The example clearly documents activities and demonstrates progress toward goals on the support plan. If you bill multiple services, you will have a timesheet for each, with space to describe the supports provided. Progress notes, progress notes, progress notes! Good example of a Case Note? Identification of any necessary changes to the goals/action plans. Return 1 -2 weeks or earlier if needed. RE: Personal Support Worker Progress Notes Dear Personal Support Worker, Starting July 1, 2016 Oregon Administrative Rules will require that all Personal Support Workers submit progress notes as part of a properly completed timesheet (other elements include time in/time out and signatures of the Personal Support Worker and Employer). Includes a summary/discussion of Addresses any outstanding issues from previous progress note.