Microsoft word - sample prog notes

GOAL: 726-Community Inclusion and Living Supports
I want to live safely in my home and continue enjoying my preferred activities there and in the community.
Description of Supports: Helping Nickel with various activities of daily living, including but not limited to:
medication management, meal preparation, hygiene, cleaning, and making his bed; behavioral supports will
also be provided. This includes receiving proper training to learn techniques to manage difficult or aggressive
behaviors. Nickel requires constant line-of-sight supervision from his providers to remain safely in his home
and in the community. He should never be left alone for any amount of time.
Red Light Progress Note: Today Nickel took his meds and had chicken salad for lunch. Nickel was happy
and asked to play board games. I assisted him with his behaviors and safety.
Green Light Progress Note Examples

Example #1
Today I assisted Nickel with taking his meds as scheduled by handing him his Paxil and Dilantin and cueing him to take them.
He needed several reminders to drink plenty of water to help him swallow all the pills. I checked his mouth to make sure he
swallowed the pills.
Nickel chose chicken salad for lunch. I assisted him in gathering the ingredients and making the sandwich, giving step-by-step
instructions. I reminded him not to put his fingers in the mayo, and provided hand-over-hand assistance when cutting the
sandwich to ensure safety.
While playing board games, I taught proper stress management techniques and provided constant line of sight supervision and
prompts to prevent Nickel from putting game pieces in his mouth.

Example #2
At the beginning of each week Nickel and I allocate his medications into his med box. I provide him the proper amount for each
day of the week and he puts this in the appropriate box with some verbal cueing. I check the med box each day we are together to
ensure that he has taken his meds on the given day. Medications were on track this month.
At the beginning of the week, we prepared a grocery list by reviewing items in his kitchen. I call out items he usually gets and he
lets me know if he has any left. From there, we determine if he needs more before our next shopping trip and I write necessary
items down. Nickel prepares some sandwiches and prepared microwave meals on his own. He does not know the appropriate
cooking temperature and timing to do stovetop cooking and has limited knife cutting experience. When we cook meals I use a
mix of demonstration, verbal cues and doing things for him. At this point, I ask him if he knows how to do something (measure,
drain, chop, etc) and when he says no I will step in. When we first started working together he would rush through cooking and
lose focus on the process. He has learned to complete the first step before moving onto the next.
I can tell that Nickel has become frustrated with whatever we are working when he begins to trip over his words and gets flushed;
he loses focus on what we are doing. I offer choices for him to take a break (sitting at the kitchen table, turning the meal off to
come back to it later, sitting in his favorite chair or on the porch where I can still see him if we can’t leave the meal).
Nickel likes to select from offered choices for recreational activities. He primarily needs verbal cueing to participate as he does not
always initiate asking questions. When in the community he requires demonstration and facilitated interactions with others.

Example #3:
Today I assisted Nickel to take his meds as prescribed by assisting him to read labels, take correct dosages and reminded him to
get a glass of water and take meds. Nickel has safety issues while in the kitchen. I assisted him to safely use knives – monitored
him around the stove. Nickel expressed interest in playing a game. I helped him choose a game and set it up according to the
rules. While playing the game Nickel became upset – yelling and throwing game pieces – I redirected him using verbal cues and
reminders about safety.
Always when working with Nickel he is monitored for safety. Progress is being made toward his goal as demonstrated 9/1 –
with redirection he was able to calm down and maintain his safety.

GOAL: 726-Community Inclusion and Living Supports
I want help accessing social events in the community so that I can make more friends and develop new
interests
Description of Supports: I need a provider who can support me in exploring my community. Jasper requires
assistance with managing his anxiety, making connections, appropriate social interactions, increasing social
skills, increasing communications skills and anger management.
Red Light Progress Note: Jasper and I went hiking and we had a lot of fun. After hiking we went to
Charburger where Jasper ordered a cheeseburger and fries. We decided that we really like the hiking spot and
will go back there again this summer.
Green Light Progress Note Example

Example #1
After discussing things he is interested in, Jasper identified hiking as an activity for exploring more of his community. I provider
Jasper with a list of options for hiking locations, and he chose Eagle Creek. Before the activity, we discussed appropriate social
interactions and trail etiquette. During the hike I modeled social skills and occasionally cued Jasper to make eye contact and greet
people. Jasper chose a place to eat from a list of options I suggested. I modeled appropriate ways to interact with the waitress and
reminded him of anger management skills he could use after he became frustrated with money handling. Jasper seems to respond
well to requesting that the cashier be patient with him while he gets his money out of his wallet. He has learned to say this ahead
of time so that he does not feel rushed and get frustrated.

Example #2
Jasper indicated he would like to go hiking. Jasper and I went to the library where I prompted him to ask the clerk where to find
information on local hikes. Jasper chose a hike near his home that was accessible and we printed a map. I provided
transportation to the trailhead. Jasper was concerned about the length of the hike and I provided the map that we printed to show
him the progress we were making. As I assured him of the time it took to complete the hike, Jasper appeared less anxious and we
completed the hike.
After the hike, we drove through town and Jasper chose Charburger after I read the signs to him and told him what kind of food
each restaurant served. I encouraged Jasper to interact with staff and communicate his order independently. I prompted Jasper on
restaurant etiquette for tipping.
Example #3
One of the goals that Jasper would like to on work on exploring his community. I supported Jasper with researching area hikes
and selecting one that supports his needs in the following areas:
- Managing his anxiety; we selected a hike that has minimal crowds. - Increasing communication skills; we visited the ranger station and I supported Jasper with communicating to a park ranger, asking questions about the hike, weather, etc. After hiking, we went to Charburger to discuss the overall experience of hiking and how Jasper felt about his communication with fellow hikers and the ranger. Jasper told me that he would like to initiate a new hike next week.

Source: http://www.inclusioninc.org/documents/sample%20prog%20notes.pdf