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The document is a Progress Notes Toolkit designed for Personal Support Workers (PSWs) in Oregon who assist individuals with disabilities. It outlines the purpose and importance of progress notes, which serve as documentation of the services provided, ensuring appropriate use of Medicaid funds. The guide includes instructions on what to include in progress notes, examples of activities PSWs may assist with, privacy considerations, incident reporting requirements, and resources for further training. Overall, it emphasizes the significance of accurate and timely documentation in supporting individuals' care and legal records.

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How to write progress notes as a support worker?

Include specifics about activities, interventions, and any changes in the clients condition. Write progress notes as soon as possible after providing care. This ensures accuracy and prevents details from being forgotten. Structure all your progress notes uniformly.

What are daily notes for support workers?

Daily care notes are a formal record that precisely represent events and the care delivered on each shift for individual service users. They have been designed to capture a more complete, personalised record of the needs, challenges and activities of the individual including health, demeanour and mood.

What are the three basic types of progress notes?

Three of the most common progress note templates include: SOAP notes: Subjective, Objective, Assessment, Plan. DAP notes: Data, Assessment, and Plan. BIRP notes: Behavior, Intervention, Response, and Plan.

How do you write a progress note?

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.

What is an example of a progress note?

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.

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How to write a good progress note?

Here are some important guidelines to consider when making progress notes: Progress notes should be recorded at the end of every shift. Progress notes can be written by hand or typed. Write down events in the order in which they happened. Include both positive and negative occurrences and anything out of the ordinary.

What is an example of a process comment in therapy?

Process comments are one form of immediacy that involve the counselor cueing the client to focus on the interpersonal process in the session rather than the session content. For example, a counselor might say When I just shared my interpretation of what you were saying I noticed your facial expression changed.

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