DDS WAIVER MONTHLY PROGRESS NOTE
Name of Individual/Consumer/Client
First Name
Last Initial
Service Provider:
Date:
-
Month
-
Day
Year
Date
Any of the following took place during the month:
ER Visits:
Yes
No
MD VISITS:
Yes
No
Include the person's satisfaction with services along with any follow-up actions, any significant changes in the person's life, results of record review(s) if completed, and any concerns regarding health and safety.
MEASUREMENT OF PROGRESS CONCERNING EACH PLAN OF CARE GOAL:
SERVICE PROVISION BARRIERS AND RESOLUTIONS:
Service provider signature
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