Intro
Daily Progress Notes help us keep track of the I/DD individual's ISP goals. You can also note tasks beyond ISP goals. These notes feed into monthly & quarterly reports for DDS Case Managers. A general rule of thumb for the length of your daily notes will be one sentence per hour worked. Daily Notes should be focused on ISP/Action Plan goals.
Multiple Goals
Clients usually have multiple goals, but they don't all need to be addressed in each note. Just focus on what was worked on during your shift.
Try to give a snapshot of the day. It’s really helpful to see what specifically you did with the client and how specifically you helped them. Even if what you did doesn’t directly relate directly to an ISP goal, the more information the better.
If you work all day with a client, a simple rubric to structure your notes can be to break your day up into sections: i.e. A couple sentences for AM, Noontime, and PM.
Progress Indicators
Daily notes can also be used to track trends. Trends of skills of independence you’ve been working on together. Trends of mental/emotional health and something that has changed recently. Trends of things they want to work on in the future, i.e. new goals, dreams, desires etc.
If progress isn't happening over time, it may be worth revisiting the goals in the Action Plan. If you spot a need not listed in the Action Plan goals, feel free to add a note so that it may be brought up for potential ISP improvements (with the Case Manager).
Example Notes for Joey
AM Notes: Morning hygiene: No prompting needed for hair. Prompted with teeth brushing, preparing & feeding breakfast, picking out clothes.
Noon Notes: Initiated a game with peers, joined social group for the afternoon, & guided throughout.
PM Notes: Evening bath/shower - refused. Negotiated for a bath tomorrow.
Other Notes: Joey threw a tantrum, took a while to de-escalate.
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