Shift/Daily Progress Note 2025

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  1. Click ‘Get Form’ to open the Shift/Daily Progress Note in the editor.
  2. Begin by filling in the Identifying Information section. Record the person's name, record number, and date of birth. Ensure accuracy as this information is crucial for identification.
  3. In the Type of Program section, check the appropriate program type and note whether it’s a Shift Note or Daily Note based on your documentation needs.
  4. Document any New Issues Presented Today. Use the provided options to indicate if there are new issues, resolutions, or if a Comprehensive Assessment Update is required.
  5. Address Goals/Objectives from the Individualized Action Plan by indicating corresponding numbers and descriptions during your shift/day.
  6. Record observations under Functioning, detailing interactions that impact placement in the program.
  7. Describe Therapeutic Interventions Provided during this period to assist in achieving goals.
  8. Assess and document the Person’s Response to Intervention, noting progress towards goals and any necessary adjustments for future strategies.
  9. Complete the Signature section with your name, credentials, date, and supervisor's details if needed. Don’t forget to include time for substance use programs.

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Progress notes in disability include important information about a clients progress, goals, events, and support plans. This helps healthcare providers, staff, and others effectively communicate with each other, make shift transitions smoother, and provide better assistance to the client.
An example of a progress note is: Attended service at 0900 to provide a personal care service. Client John Doe was in bed on my arrival. I picked up all the laundry for the wash, put away the dishes, and went to wake John at 0915 for his 0930 medication.
While a SOAP note follows the order Subjective, Objective, Assessment, and Plan, it is possible, and often beneficial, to rearrange the order.
Progress notes record the date, location, duration, and services provided, and include a brief narrative. Documentation should substantiate the duration and frequency of service delivery. The narrative should describe the following elements: Clients symptoms/behaviors.
How to write a progress report Step 1: Understand and tailor to your audience. Think about wholl read your report. Step 2: Begin with a clear executive summary. Step 3: Adopt a consistent and clear format. Step 5: Stay objective and fact-focused. Step 6: Review, refine, and edit.

Key Facts about the Shift/Daily Progress Note Form

Required for Multiple Programs

Documentation Links to IAP Goals

Identifying Information Required

New Issues Section

Goals/Objectives Tracking

Response to Interventions Documented

Billing Strip Completion Instructions

Required for Multiple Programs

The form is mandatory for various programs including Crisis Stabilization Unit (CSU), Detox Level III, CSS, Intensive Residential Treatment Program (IRTP), and Respite.

Documentation Links to IAP Goals

All documentation must connect to specific goals outlined in the Individualized Action Plan (IAP).

Identifying Information Required

Essential identifying information includes the person's name, record number, date of birth, and organization name.

New Issues Section

Staff must document any new issues presented by the person during their shift, with options for resolution or further assessment.

Goals/Objectives Tracking

The form requires recording specific goals and objectives addressed during the shift/day as per the IAP.

Response to Interventions Documented

Providers must assess and document the person's response to interventions and progress towards goals and objectives.

Billing Strip Completion Instructions

The form includes detailed instructions for completing a billing strip, including date of service, provider number, location code, and diagnostic code.

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People also ask

The end-of-shift nursing report is an opportunity for the off-going nurse to provide the on-coming nurse with important details regarding a patients medical history, status, and any upcoming tasks or concerns that need to be addressed.
Progress notes should outline the evidence-based practice used in the session, and comment on any changes in modality. You might also include any skills that may be helpful for clients to practice to help manage or reduce their symptoms, and why it would be helpful in reducing their symptoms.

daily progress note template