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  • Waiver 245D Progress Notes

    Progress Note Instructions
  • Progress notes must clearly identify the service type provided and reflect the individual's Coordinated Services and Supports Plan (CSSP). Notes should describe the service delivered, the individual's participation, and progress toward increased independence.

     

    STAFF ARE NOT ALLOWED TO ADMINISTER MEDICATIONS TO CLIENTS.

  • Example of a Weak Progress Note

    Example 1 - Too Vague
             Worked on goals today. Client did well and was cooperative.

    Why this is weak:

    • No service type
    • No CSSP goal referenced
    • No description of the service
    • No measurable progress


    Example 2 - Task-Based Only 
            I assisted client with cooking and cleaning.

    Why this is weak:

    • Lists tasks, not skill-building
    • Doesn't connect to independence
    • No client response or progress

    Example 3 - Opinion-Based

    Client seemed lazy today and did not want to participate.

    Why this is weak:

    • Subjective and judgemental 
    • Not DHS-appropriate language
    • No attempt to describe barriers or supports

    Example of a Strong Progress Note

    Example 1 - Skill Building (In-Home Support)

    Service Type: In-Home Supports


    I supported the individual with meal preparation to address the CSSP goal of increasing independent cooking skills. The individual followed a visual recipe and independenly completed 3 of 5 steps with verbal prompting. The individual demonstrated increased confidence compared to previous sessions and required fewer prompts. Continued support is needed to build consistency.

     

    Example 2 - Community Participation


    Service Type: Community Living Skills

    Staff supported the individual in practicing appropriate social interactions during grocery store visit to support the CSSP goal of increasing community independence. The indivual greeted store staff independently and followed a shopping list with minimal redirection. The individual required reminders to remain on task but showed improvement from prior visits.

     

    Example 3 - Employment Support

    I provided employment support to assist the individial with identifying job opportunities to support the CSSP goal of obtaining competitive employment. I supported the individual in completing two online job applications and practiced interview skills using sample questions. The individual independently indentified one job of interest and required verbal prompts to complete application sections. The individiual demonstrated increased confidence and engagement compared to previous sessions. Continued support is needed to strengthen job search and interview skills.

     

    Example 3 - Education 

    Supported the individual with exploring education and training programs to support the CSSP goal of increasing vocational skills. The indiviual identified one program of interest and required verbal prompts to organize enrollment steps. Progress was noted in decision-making and self-advocacy.

    Why this is a strong note

    • Clearly indentifies service type
    • Directly ties to a CSSP goal
    • Describes what staff did
    • Shows client partification 
    • Demonstrates progress tward independence
    • Justifies ongoing service need

    USE POSITIVE SUPPORT LANGUAGE

    EXAMPLES

    1. Encouraging Effort and Participation

    2. Reinforcing Skills or Progress

    3. Promoting Independence

    4. Positive Behavioral Support

    5. Motivational/Encouraging Words

    Tips for Using Positive Support Language in Progress Notes

    • Be specific: Instead of "did well". say what was done well
    • Focus on effort and skill-building, not judgement.
    • Ties to CSSP goals/area's of support: Always connect positive language to measurable progress.
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  • Clear
  • BEFORE SUBMITTING, CONFIRM THAT THE NOTE INCLUDES:

    • Correct service type selected
    • Alignment with the CSSP goal(s) or area's of support
    • Clear description of what staff did
    • Description of client participation/response 
    • Evidence of progress, skill-building, or need for continued support
    • Objective, factual language (no opinions or assumptions)
    • Use of Positive Support language
    • Enough detail to show why the service was necessary
  • Should be Empty: