Progress Note Writing for Supported Home Living, Group Home and Foster Care Providers

By Andrea Tippit, QM Director

Handwritten Progress Notes 101 Progress notes should have the basic

elements in them: Who When Where How Long How Provided What Why Consumer’s Response to Service

Who, When, Where, How Long The billing strip should capture these basic elements for you. Who – The Client’s Name

Remember – if you are providing services to a person and someone else, this needs to be documented. Make sure it is billable (e.g. Client and Other – if at doctor’s office; Client and Parent – if providing services to child & parent; etc…)

When – Date of Service Where – Home, Office, Other

Choose or document the correct code. If you put “other” you need to specify where in the note

How Long – Start and Stop Times It is fraud to not accurately document the time you spent with the

person served. This means that if you are not providing services, that time should not be billed. Do not round your times. If you start services at 8:26 am, put that down.

How and What Go Together Typically you use a verb, adverb, noun, pronoun together. Some examples are:

Assisted Bob in preparing a healthy lunch. Trained Sue to microwave her frozen dinner.Observed Jack as he made his bed, providing verbal prompts to tuck ends in. Taught Jackie to use measuring cup for laundry detergent.Guided Billy into the living room from bedroom, with physical assistance.Gave Susan a bath, as she requires full assistance.Helped Roxanna bathe, using verbal prompts to wash her private areas and hand over hand to wash hair.

How and What Go Together Showed Mark how to make grilled cheese, using hand

over hand to turn sandwich with spatula. Modeled putting on socks for Jim, then had Jim

attempt. Praise given as one sock put on correctly. Prompted Alex to put his clothing on. Three prompts

needed. Andrew practiced bouncing basketball for exercise and

eye-hand coordination. Changed Jack’s adult diaper/brief three times today.

One bowel movement and two just wet. Prepared Sue’s meals for 2 days. Placed them in

microwavable containers.

Why Sometimes you will need to explain “why”

you provided the service. If the service is a planned or routine service, many times this will not be necessary. Other times, you will want to explain why you did something, especially if it is new, unique, invades someone’s personal space/boundaries or may not be spelled out in the plan, but necessary to accomplish the goal/service.

Why – Continued…Here are some examples of “why” statements: Helped Bobby eat lunch by spoon-feeding him as

he cannot hold spoon and he wanted soup. Escorted Susie to couch to sit, as her gait was

unsteady this morning. Gave Theresa a bath because she broke her arm

and can’t bathe herself. Theresa gave permission for assistance.

Helped Amanda pick out low carb, low sugar foods at grocery store because her doctor asked her to decrease these things in her diet.

Consumer’s ResponseThis is a statement or two of how the person responded to the service(s) provided. These should be in the person’s own words. If the person does not speak, an observation that is objective about how the person seemed to respond. For example: Jack seemed more relaxed after his bath as observed by less

spastic arm movements. Joe said “I like peanut butter toast for breakfast” and smiled. Kathy seemed to enjoy going to the store. She said that she

likes pushing the cart. Jennifer expressed she didn’t like people helping her bathe

by swatting at staff and glaring during the process. Staff attempted to provide her dignity by covering her with towel in bathtub until area needed to be washed.

How much to write? This is a question that cannot be easily

answered. Sometimes a sentence or two is all that is needed. Sometimes, you will write several paragraphs. The goal is to be clear, concise and yet explain what service(s) you provided.

If you provided an “all day” service – one or two sentences clearly isn’t enough. If you were only there for 15 minutes, you may have accomplished a lot and may need to write a large paragraph, or you may not.

How much to write, continued… There are several methods in writing.

What really needs to be remember is this: Does the note you describe

the service(s) provided? if the service helped the person/was

beneficial? the person’s response to the service? any new issues or concerns and what

should/could be done? Or if you addressed them?

How much to write, continued… Remember not to put your opinion(s) in the note. Don’t put other consumer’s names in the note. If there was an incident, accident, injury, seizure or

restraint – you must complete an incident report and contact the nurse/supervisor immediately!

Don’t use “white-out” or scribble out a mistake! Use one line through the error, note that it is an “error” and initial it; then write the word correctly.

Watch your spelling. Remember, progress notes are part of the person’s clinical records. They can be read by the person served, family members, legal people, etc….

Community Supports, Support Home Living, Group Home or Respite Care Example:

Jack awake when staff arrived. Assisted him in toileting, bathing and dressing prior to breakfast. Prepared eggs, toast and juice. Jack ate 75% of meal. Jack brushed teeth requiring hand-over-hand assistance to get back teeth (see tracking sheet). He washed face w/o prompting. Jack expressed excitement to go to day hab, as he smiled and wheeled himself to the door to wait for van.

Supported Home Living or Community Supports Example:Assisted Theresa in making a grocery list. Theresa insisted she needed milk, eggs, soap and detergent though she had plenty of each item. She cursed at staff when informed of this fact. Transported to grocery store and assisted choosing items from list, based upon prices and nutritional content. Theresa put items listed above in basket. Advised of budget and need to remove other items to equal the value of additional items, providing choices. Theresa yelled “You’re mean” at staff. Staff quietly reminded Theresa of plan that if yelling in public, we are to leave and return home. Theresa continued to yell. Groceries were taken to clerk to put away, with apology. Staff took Theresa home. Reviewed with Theresa what she had in pantry to eat/cook and re-scheduled shopping trip.

Group Home or Foster Care Example:

John whistled and smiled most of the day. He helped clean the breakfast dishes. John did not argue with any of his roommates today. He helped choose the movie, agreed to sit in the back of the theater and only got up 4 times during the movie. John stated “I had fun today!” John completed all daily living skills except brushing teeth, without prompting. See tracking sheet for details.

Group Home or Foster Care Example:

Jane woke up in a bad mood, as evidenced by yelling at staff and roommates. She was unable to express what was causing her frustration. Jane denied complaints of pain, when asked. Staff provided opportunities for Jane to have space away from other people, encouraging her to help staff garden in the back yard after breakfast. Positive feedback provided to Jane for helping weed the flower bed, which resulted in a smile. She was encouraged to eat healthy meals and drink fluids throughout the day. Jane went to bed early (8:00 pm) after taking her medications and showering. Informed next shift of Jane’s issues, today in order to monitor health and sleep patterns.

Support Home Living or Community Supports, example:

Staff helped Ralph clean his apartment as per plan. Ralph required multiple prompts to pick up clothing and other items from floor. Reviewed rules of housing authority and upcoming inspection. Modeled how to rinse dishes and load dishwasher, then had Ralph demonstrate skill. Praise given for rinsing dishes before putting into dishwasher. Reminded Ralph to do this as soon as meal is over, to prevent stuck on food. Ralph refused to clean toilet saying “it’s gross!” Discussed ways to ensure the toilet is “less gross” by standing closer, wiping seat down if “drips” occur, using anti-bacterial wipes after use, etc… Ralph said he wants gloves. Put cleaning gloves and wipes on the grocery list posted on the refrigerator.

Provided Hourly Respite to Steve at the Kingsville Center.  Steve seemed happy to see his friends who also attend the Saturday Program, greeting them with smiles and “high fives.” Steve asked staff what activities they would be doing today. When staff replied, Steve stated “That sounds fun!”  Steve interacted with his peers well while participating in the different activities.  Steve ate the lunch that staff prepared. He assisted with the clean-up.  Steve chose to watch a movie after lunch while his peers completed crafts.  On the way home Steve told staff that he had fun today but he was very tired.

Example note for hourlyRespite Saturday Program

Example note for Community Supports

Provided Community Supports to James out in the Portland community.  James was happy to see staff today. He said he was excited to be going somewhere.  He chose to attend the local Wal-Mart to look at items that he wished to purchase.  While shopping James talked about how he is looking forward to the summer months and wondered if his family would be doing any vacationing.  James was able to purchase a movie that he liked.  Staff assisted with making the purchase by providing verbal prompts with counting change from the purchase, as noted on his tracking sheet.  Staff verbally praised James for his good money management skills which made him smile.  James also chose to get lunch at the Dairy Queen during his outing.  During his lunch meal James talked about school and his friends.  After the meal, James said he was ready to go home. James said that he likes going out and getting out of the house. He stated that he was looking forward to his next outing.

Example of Hourly Respite one to one

Provided individual hourly respite services to Candace in the Sinton community.  Candace was hesitant to go with staff however with encouragement from family and staff she went.  Candace chose to go to the local library to look at books and use the computer.  She also asked staff to take her to get an ice cream at Whataburger which she order herself.  While eating her ice cream staff verbally praised her for participating in the outing today and talked about what things she would like to do on her next outing.  Candace began to give staff a list of activities, to include going to the mall, the aquarium and to see a movie.  Staff transported Candace home and explained to her that staff would call when it was time for her to go on an outing again.  Candace stated that she “liked going to the library and eating ice cream” and asked when staff would call again. Staff showed her a calendar to help her understand that staff will call in a couple of weeks to go out again.

Example of SHLProvide Dan SHL in the Portland community.  Staff arrived at Dan’s home and asked Dan what items he needed from the grocery store.  Dan began to list items and staff assisted him with making the list.  Then staff accompanied Dan to the grocery store to assist with finding the needed items and completing his purchase.  Dan was able to find all the items on his list.  Verbal prompts were required, as noted on his tracking sheet when he passed the candy isle in the store.  Dan wanted to purchase some candy and staff verbally reminded him of what his doctor told him during his last visit about eating too much sugar.  Dan voiced understanding and chose not to purchase the candy.  Staff verbally praised Dan for making good healthy choices and also for his shopping skills.  Once at home, Dan put away all of his items and stated that he was ready to rest for the afternoon.  

Example of Day Hab note (Your Day Hab note should be specific to the person and all the activities they participated in during their time at the center)

Chuck arrived at the Beeville center and greeted his peers and staff each day that he attended.  Chuck talked this week about what he did over the weekend and showed off the new clothes that he was able to purchase during a family shopping trip.  On Wednesday Chuck became upset with one of his peers because they had a soda and he did not have any money to buy one for himself.  Staff explained to Chuck that he could ask his family to send him some money and he could purchase a soda when he came back to the center.  Chuck was able to finish out the day without any further conflict.   Chuck participated in math skills on Monday and Thursday; health on Tuesday pertaining to oral hygiene; safety skills on Wednesday pertaining to smoke detectors; artistic expression on Monday-Thursday; participated social roles and kitchen skills training Monday, Tuesday and Thursday; reading and writing skills on Thursday; positive attitudes on Tuesday; on Monday group discussion on feelings.  Chuck worked on his individual training skills, Thursday, pertaining to money management as noted on his tracking sheet.