Daily Notes

Daily Notes

Hey, thanks for spending time with someone today, and being a part of assisting them in living their best life! Their notes need to show how their activities align with their ISP goals. Also, they'll get summarized for monthly and quarterly reports. Please select the client you worked with today, and enter notes from the session.
Your Name*

First NameLast Name
Service Date*

MonthDayYear
Date care was provided, that these notes are applicable for.
# of Hours (this shift)*
Your Role?*

Sophia's ClubhouseAs a Parent/DSP
Which Clubhouse Client did you work with?*
Choose your superhero! -- **For any other clients, select 'As a Parent/DSP' above.
Client Name you worked with (i.e., your kiddo or other)?*
Superhero name
Today's Rating on progress toward ISP goals?*

1

2

3

4

5

1 is Not Met, 5 is Well Met
Explain what you did today with your client, & how you helped them. Ideally, related to their ISP goals.*
Only include your opinions when necessary. For example, for the purposes of tracking trends.
(Optional) Any additional feedback on the day?
Additional comments on the day

Notes Guidance

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: Morning hygiene: No prompting needed for hair. Prompted with teeth brushing, preparing & feeding breakfast, picking out clothes.
Noon: Initiated a game with peers, joined social group for the afternoon, & guided throughout.
PM: Evening bath/shower - refused. Negotiated for a bath tomorrow.

Other Notes: Joey threw a tantrum, took a while to de-escalate.

Helpful Words (synonyms)

Administered	Educated	Planned
Advocated	Encouraged	Prepared
Analyzed	Evaluated	Pre-taught
Assessed	Expedited	Prioritized
Assisted	Explored	Recommended
Clarified	Facilitated	Referred
Coached	Familiarized	Rehabilitated
Collaborated	Guided	Represented
Communicated	Helped	Reviewed
Completed	Informed	Scheduled
Coordinated	Instructed	Strengthened
Corresponded	Monitored	Supervised
Counseled	Motivated	Supported
Demonstrated	Negotiated	Trained
Developed	Organized
Directed	Participated

Should be Empty: