Turning “BLAH” Home Visit Notes Into The IDEAL Story

Laura Schertz MS, OTR/L, Chantel Jno-Finn PT, DPT, Wendy Pittard, BS Elem Ed

TRUE or FALSE

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Objectives1. Learn to structure your documentation to include the necessary &

ideal components of a home visit note.

2. Identify methods to ensure your documentation is reflective of IFSP outcomes & parent involvement.

3. Discuss & share strategies for completing notes that are timely, helpful for families, & comply with guidelines for licensure, reimbursement, & state compliance.

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The ProblemWhat is it about EI documentation that is so difficult?

Why does it matter?

What are YOUR hang-up’s?

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What does the Provider Appraisal

Review (PAR) Handbook say??

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The VItal MessageThe focus of Alabama’s EI System is to train, equip, & support parents/ caregivers in being the first & best teachers for their child

6 Core Values• Family Centered

• Developmentally Appropriate

• Individualized

• Natural Environment

• Train/ Equip

• Collaborative

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PAR/ TA Review Checklist• Provider notes reflect family training

• Provider notes reflect adequate caregiver plan

Documentation Reviewed During or In Preparation for TA/ PAR

Provider progress notes (includes “no-show notes”)

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Handout with PAR Documentation Requirements:

Let’s Take A Look

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Follow the PAR Handbook!!

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Structure For Writing Notes

(per PAR)

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Progress Notes MUST Include…. • EI service provided

• Date of visit

• Length of visit (begin & end times)• Documentation of visits adhere to frequency/length on IFSP

• Reason if visit is shortened

• Provider Signature

• Services provided by Paraprofessional, SI Aide, LPTA, &/or COTA• Documentation of supervised visits every 6th visit or every 90 days

• Note must be signed by supervisor & parapro, SI Aide, LPTA &/or COTA

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Progress Notes MUST Include…. • IFSP outcome(s)

• Verbatim

• Identify outcome(s) addressed

• Language easily understood by family/caregivers & other providers

• Strategies or techniques shared with family/caregiver which relate to outcomes you addressed (summary of visit activities)

• Individualized family/caregiver plan to implement in-between visits

• Timeliness 17

Marty McFLy VIdeo

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Helpful Tips, Scenarios,

& Note Examples

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Suggested Flow, Content, & Tips1. What happened since last visit

2. What you did during the session

3. How the caregiver actively participated in the session

4. How the child responded to the strategies

5. What supports & suggestions were developed for follow-up during daily routines, prior to next visit (i.e., the joint plan)

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Suggested Content, Tips, & Questions to Ask Yourself“Susie was seen at home with mom & baby brother.”

Did I include updates since last visit?

1. What happened since last visit• How have things gone? What did they practice & what was the response?

Any progress?

• Recent doctor appointments, other therapy sessions, etc.?

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2. What you did during the session3. How the caregiver actively participated in the session4. How the child responded to the strategies

• Document what you observed the child doing, the child’s response, the response of the caregiver, & family education.

• What IFSP outcomes were addressed & HOW?• Did I describe the kind of support, teaching, modeling that was provided?• Document strategies that were discussed & utilized.• If you wrote “parent indicated they will try the suggested strategies,” be sure to

actually include the strategies!

• Did I describe the caregiver’s involvement? HOW they participated?• Notes need to indicate family/ caregiver training, not only observational

Suggested Content, Tips, & Questions to Ask Yourself

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Writing your note as the last part of the visit can help facilitate discussion about what happened & plan to move forward.

5. What supports & suggestions were developed for follow-up during daily routines, prior to next visit (i.e., the joint plan)

Suggested Content, Tips, & Questions to Ask Yourself

Joint Planning• NOT the same as “prescribing homework”

• Begins with a simple question….

• It is ok to only focus on 1-2 strategies

• Make sure it’s very specific• Write it down!• Follow-up 24

Tips for Note Writing• If you’re addressing an outcome & documenting it in the main body of

your note, you also need to address it in home activities• Be sure to tie all 3 parts of the note together: the outcome written at the top

of the note, what you worked on, & home activities for in between visits

• Link documentation back to IFSP outcome you’re addressing.

• You can use their own words to describe concerns, notate strategies they developed, or to write what to work on in the meantime

• It is ok, & encouraged, to include measurable components in your documentation! 25

Common Mistakes in Notes & Suggestions • Only focusing on what the child does/ what you observe

• Need to show your skilled interventions!!

• Why is skilled intervention needed for this child & family?

• How did you incorporate family coaching & education into the session?

• Demonstrate the importance of our role for the child & the family, in addition to the child’s progress.

• Including a list of toys or activities used during the visitMore important to:

• Document the child’s response to the toy/ activity OR

• Strategies used to promote successful play with that toy/ activity 26

Common Mistakes in Notes & Suggestions• Trying to document every skill addressed or every behavior you observe

• Focus on what’s different. Document the progress of the child as well as the family education component.

• What did the child do this session that was unique or different from previous sessions?

• How did the child respond to a certain cueing strategy from the parent?

• How was the environment or task modified in order to support the child’s participation?

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Questions To Ask Yourself….• Does my note meet all the necessary PAR criteria?

• Does the note reflect family centered services that are individualized & developmentally appropriate?

• Is the natural environment reflected (where & who)?

• Is family training/ caregiver education clearly addressed (not just that you did it, but the caregiver’s participation in the training)? How do you know the caregiver will be able to follow through?

• Did collaboration occur between yourself & the caregiver?

If someone read my note, would they know that I understand the 6 core values?

IN SUMMARY

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Marty McFly Note

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Applying What We’ve Learned

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Groups: Review Good Notes• Meets the necessary PAR criteria

Identify Examples of the 6 Core Values• How does the note reflect family centered services that are

individualized & developmentally appropriate?

• Natural environment is reflected (where & who).

• Family training/ caregiver education is clearly addressed, specifically noting the caregiver’s participation. When reading the note, you can tell the caregiver will be able to follow through.

• Do the activities from the session, & for in the meantime, reflect collaboration between the provider & the caregiver?

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Groups: Review Sub-“PAR” NotesQuestions To Ask Yourself….

• What needs to be added to meet PAR criteria?

If someone read my note, would they know that I understand the 6 core values?• Does the note reflect family centered services that are individualized &

developmentally appropriate?

• Is the natural environment reflected (where & who)?

• Is family training/ caregiver education clearly addressed (not just that you did it, but the caregiver’s participation in the training)? How do you know the caregiver will be able to follow through?

• Did collaboration occur between yourself & the caregiver? 32

Real World Brainstorming

Handwritten or electronic?

Real-time or after-the-fact?

When you don’t have enough time to write the note?

All those IFSP outcomes….

When all current outcomes, related to you, are met?

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Let’s Discuss!! Any Questions?

Lauralschertz@childsplaytherapycenter.com

ChantelChantel.Jno-Finn@childrensal.org

Wendy wpittard@ucphuntsville.org

Contact Us!

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“Turning Blah Home Visit Notes into the IDEAL Story” 2016 EI & Preschool Conference

PAR COMPONENTS Taken from the AEIS PAR Handbook, revised 10/01/2016

100% OSEP Target Indicator: Timely Services All early intervention services are initiated or attempted within 30 days of service begin dates.

Provider notes document timely service delivery (service provider note with date) or attempts to schedule within 30 days of service begin date (“No-show” note)

At least one service must reflect the begin date of the IFSP Service coordination notes document barriers to providing timely service delivery Justifications for delays are entered in GIFTS as they occur. (Delays can be justified based on family reasons but

cannot be based on programmatic issues)

COMPONENT: Child Find Referral, Initial, & Annual Eligibility Determination Initial Eligibility & Annual Eligibility can be based on developmental delays with the following:

Two appropriate procedures are conducted to confirm delays of 25% or greater in at least one domain on both procedures. (at least one of the following 5-part procedure must be administered: DAYC2, ELAP, IDA, Battelle2)

Report of appropriate evaluation completed prior to referral date by external entity may be used but must reflect child’s age, date of evaluation, & reports should not be more than 90 days old.

When there are conflicting results between the 2 evaluations procedures used to determine eligibility, a 3rd tool must be used. The 3rd tool must be completed by a 3rd evaluator. All evaluators must have different disciplines.

Initial Eligibility & Annual Eligibility can be based on documented diagnosis with the following: One appropriate 5-part procedure reflects child’s age performance relative to 25% delay (at least one of the

following 5-part procedure must be administered: DAYC, ELAP, IDA, Battelle, DP-3) Medical documentation pre-dates eligibility.

For Initial Eligibility qualified evaluators (personnel standards) use Informed Clinical Opinion with the following: Basis is detailed & clearly documented in a report for eligibility determination with indication that at least one of the following three criteria has been met & documented in the child's record:

Borderline performance (22-24%) on two age-appropriate procedures. One procedure should be completed by a specialist (OT, PT, SLP). The written opinion should include information regarding how these concerns effect the child’s ability to function during a routine the child’s family has identified as a concern.

Specialist (OT, PT, SLP) whose expertise best addresses a specific area(s) of concern evaluates the child &

provides test results & written opinion explaining why the child qualifies for early intervention services. The written opinion should include information regarding how these concerns effect the child’s ability to function during a routine the child’s family has identified as a concern.

Physical or mental condition (a physician or the specialist within his/her discipline may establish the description of the condition) that does not meet standards for qualifying diagnosis. The written opinion should include information regarding how these concerns effect the child’s ability to function during a routine the child’s family has identified as a concern.

Child is re-evaluated within 6 months, & if not determined eligible based on standard procedures/diagnosis, is exited from AEIS.

Initial & Annual Eligibility Reports address all of the following: (use EDR/ AEIS form which meets federal criteria). Statements of child’s performance relative to 25% delay Confirmation of 25% delay(s) on two procedures or medical documentation plus one 5 part procedure. Total score

for communication (receptive & expressive) & physical development( fine & gross) are combined Hearing & Vision Screening Name, credentials, & signatures of evaluators on individual reports &/or physician documentation

Name & signature of service coordinator (as summarizer) Summary date is same as eligibility date (in GIFTS) Brief report of child history Evaluator observations & concerns per domain Parent observations & concerns per domain A detailed report must be completed when a domain specific evaluation (PLS, Peabody, etc.) is administered. (Do

not use the EDR format created by AEIS state office) Dates of evaluations Basis of eligibility is clear Confirmation of native language or native mode of communication used unless clearly not feasible to do so Accurate calculation for test result including prematurity SC is expected to provide families & team members a copy of the Eligibility Determination Report Child is not determined eligible nor ineligible based solely on one procedure (team must conduct two procedures

or have qualifying documented diagnosis ) Child is discharged if eligibility standards are not met AEIS/EDR & Summary form which meets federal criteria developed by the State Office must be used when

completing a 5-part assessment (DAYC, ELAP, IDA, Battelle, DP-3)

COMPONENT: Individualized Family Service Plan, Natural Environments Service provider addresses functional outcomes on IFSP which includes family/caregiver training (attempted visits are documented by service provider as “No-show” note). Progress notes include:

EI service provided IFSP outcome(s) are listed on provider note. Outcome(s) listed on the provider notes are identical to the outcome(s) listed on the IFSP (must be verbatim) Outcome(s) addressed during the session are identified (checked/circled/highlighted) Date of visit Length of visit (begin & end times) Documentation of provider visits adhere to frequency/length on IFSP (reason noted if visit is shortened) Documentation of supervised visits when services are provided by a Paraprofessional, SI Aide, LPTA, &/or COTA

(every 6th visit or every 90 days must be supervised). Documentation must include who was present within the content of the note (ex: Mom, child & PT supervisor was present during today’s session) & the note must be signed by the supervisor & the paraprofessional, SI Aide, LPTA &/or COTA.

Used language easily understood by family/caregivers & other providers Strategies or techniques shared with family/caregiver which relate to outcomes (summary of visit activities) Individualized family/caregiver plan (to implement in-between visits) Provider Signature (parent signature may be requested but is not required) Timeliness of documentation (not later than 30 days after service delivered)

Valid Attempt is defined as documentation of Service Coordination &/or provider contacts &/or attempts to contact (last contact should be within 3 business days of appointment) & at least one of the following within the file: 1.) No show by parent, 2.) Multiple rescheduling of visits, 3.) Traveling back/forth in attempt to deliver service(s)

IFSPs, service coordination notes & provider documentation reflect culturally competent practices by all team members with respect for the diversity of children & families. Family preferences based on beliefs, values & routines are respected & integrated into team decisions.

Service Coordinator reviews provider progress notes for accuracy & compliance.

COMPONENT: Procedural Safeguards Native language or other mode of communication is used for evaluation procedures, procedural safeguards & IFSP meetings (unless clearly not feasible) for families who are not proficient enough to understand or use English.

Use of native language or mode of communication documented on evaluation report Barriers encountered to finding interpreters & alternate strategies for testing explained

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ANNOTATED GUIDANCE FOR WRITING EARLY INTERVENTION SESSION NOTES Retrieved from Pennsylvania Training & Technical Assistance Network, Adapted for the 2016 Alabama EI & Preschool Conference

Documentation of early intervention service delivery must be completed by an early intervention professional when IFSP services are delivered to a child as well as when planned service delivery does not occur. Notes should be written legibly so that they can serve as a resource to the family or caregiver or other team members and service providers.

Child and Family Outcome Update:

Update information about the child and family related to any changes in medical, educational, social, developmental or other services. Document how the activities, strategies and recommendations from previous sessions are actually working. Note any data collection that may have been gathered or collected by the family or caregiver to help instruct and support service delivery.

Questions to prompt discussion with the family or caregiver: Examples of documentation Assess child and family well being

“How has Laura been? Did her cold go away?” “Is grandma out of the hospital?” “Has dad gotten any break from overtime duty?”

Review activities from the last visit. Get reactions to activities and identify family’s satisfaction

“During our last visit, we tried using the choice board to reduce temper tantrums during getting dressed. How did it go?” “You were going to try putting the snack choice board on the refrigerator. How did that work?” “We played on the swings and in the sandbox last week. Did he ask for more?”

“How did using the toy grocery cart work for increasing her walking? Did she chase you? Did you have fun?” “Did bath time take longer when you added big brother as a conversation partner?” “How much extra time was involved with Danny helping put the clothes away?”

Revisit child outcomes on IFSP and solicit family feedback on child’s current status to keep the “big picture” in focus.

“We’re working on Cara’s vocalizations to help her develop words. What sounds have you heard this week? Is this still a priority?”

Laura was seen at the dr. this week for an ear infection

Dad is on overtime and was unable to take Joey to the park.

Mom used the choice board during breakfast and he picked Cheerios without a tantrum.

Emmet asked for more when he was on the swing and when he wanted juice for the first time yesterday.

The grocery cart did not work because all Latoya wanted to do was play with the stuff in the cart.

Danny helped put his clothes away but lost interest after 2 minutes.

Mom has heard 3 new sounds and this continues to be a priority.

What we did today to address the outcome: Include how intervention was embedded within activities and routines, family participation and how strategies were used Include how the family member or caregiver was involved in the visit. Session notes need to contain documentation that services are being delivered within the context of the family’s or early childhood setting’s routines and in a manner that is functional for the child. The note needs to give a clear, unique and detailed description of the visit. Include what was discussed with the family or caregiver regarding suggested activities and strategies and how to use the particular activity during daily routines. Include specially designed instruction, supplementary aids and program personnel supports, home or program modifications and training and materials used by the family or therapist. Session notes that consist of mere observations do not meet regulatory requirements.

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Things to include Examples of documentation

How services provided were within the context of everyday activities, routines, and settings

Ways you actively engaged the family that promoted child development, learning and growth

Description of how the strategies were used

Showed mom how to prop Sally in the grocery cart. Mom suggested using her coat as support.

Dad hid the toy under the blanket and encouraged Jack to look for it. Jack was able to find the toy.

Modeled waiting for a response from Cody when asked if he wanted to play with the blocks. Mom and Grandma practiced.

Strategies used: Early intervention services need to be provided in a manner that will positively impact the family or caregiver’s ability to successfully support the child’s participation in daily activities. General coaching strategies such as conversation, information sharing, observation, joint interaction, planning and review or summary are important throughout the visit. The early interventionist should choose specific strategies that best match the learning style of the family or caregiver as well as the child. Put a check in the box next to each of the specific strategies that were used.

Direct teaching Demonstration

Guided practice w/feedback Caregiver practice w/feedback

Problem solving

Reflection Other:

*Please include how the strategy was used in the narrative. Strategy What this strategy looks like in practice Direct Teaching

The early interventionist shares information about a specific strategy or routine with the intent for the caregiver to learn how to use them or understand the value. The child may or may not be included in the interaction until you have explained how to use the strategy and how it helps to support development. A handout or video clip may be used for support.

“If you help him keep his trunk stable, he is better able to reach for toys. If he isn’t steady, he can’t reach as easily. Place your hands right here…just like this to provide the most stability.”

“Mirroring is a strategy we can use to increase his imitation skills. To use this strategy we just do what he does and copy his actions. So, if he drops a block in the bucket, you drop a block. This will keep him engaged in the interaction and show him the power of imitation.”

Demonstration The early interventionist takes the lead in demonstrating a strategy with the child while the caregiver observes. He or she sets up the demonstration by telling the caregiver what she is going to do and why. The early interventionist narrates during and after the demonstration with the purpose of showing the caregiver how to use the strategy. Demonstration may be repeated and may evolve into guided or caregiver practice with feedback.

The early interventionist shows the baby the bottle, sets it on the table, and then points while saying to mom “I’m going to point to the bottle and then wait 3 seconds to see if he requests it with a gesture or vocalization.”

The early interventionist works directly with the child using least-to-most prompting to encourage finger feeding while she explains the technique to dad.

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Guided Practice with Feedback The early interventionist and caregiver work as partners with the child and exchange roles in practicing intervention strategies. The early interventionist guides the interaction with specific suggestions about caregiver behavior in the context of a routine and demonstration of strategy use. The caregiver has a turn (or multiple turns) to practice using the strategy with the child as the early interventionist makes suggestions during the interaction and offers feedback following the routine.

During snack, the early interventionist says, “Here are two goldfish for her to eat. Let’s see what happens if you wait a little longer before offering her more.” Child eats and looks at mom and mom reaches out with another goldfish. The early interventionist models the word ‘more’ and coaches mom to say ‘more’ before giving her another goldfish. Mom asks how long to wait and how many times to repeat the label.

Cara is tantruming. Dad positions himself in front of her with two toys. He holds them while the early interventionist supports Cara with hand over hand to make a choice from dad as he labels and offers them to her.

Caregiver Practice with Feedback The caregiver takes the lead in interaction with the child as the early interventionist observes and supports the interaction as needed. Support is offered by providing feedback specific to the caregiver or child’s behavior, offering encouragement, or asking a reflective question without interrupting the routine. The early interventionist is less actively involved or ‘hands-on’ than in either guided practice or joint interaction.

Mom is working on pausing to give Amy time to take a turn rather than asking “What’s that?” As mom and Amy look at a book together, mom waits after reading the title. Amy vocalizes and mom turns the page. Amy points, vocalizes, and looks up at mom to ‘tell’ her about the picture. The early interventionist says: “Wow! I heard her say doggie and ball – all that extra time gave her a chance to comment! She led the story and you followed her lead.”

Problem Solving The caregiver and early interventionist consider and discuss strategies to improve routines and outcomes. Both parties contribute, define, or clarify solutions to a problem, situation or concern and develop an action plan for when and how the strategy will be used in a routine.

“He seems to throw the ball away from you. How do you think we could help him roll the ball toward you?” Mom responds: “Maybe if I hold the laundry basket, he can throw the ball into the basket.” The early interventionist says. “Let’s try it. You could even say ‘ready, set, go’ to get his attention.”

Dad says “He eats one bite from the spoon and quits.” The early interventionist asks, “Does he eat more of some food than others?” Dad responds with “I don’t think so. But he definitely likes some foods more than others, like bananas. You can’t even get them in his mouth.” The early interventionist asks “How much does he eat if he can feed himself with his fingers?”

Reflection The early interventionist and caregiver discuss an activity or routine that is completed, watch a video of the caregiver interacting with the child, or following an observation of the child or situation, reflect on successes and areas for improvement, what factors impacted the outcome, and how strategies could be used in other settings or expanded to include other outcomes.

“Let’s watch this video together to see how he responded when you used environmental arrangement to encourage him to make requests during breakfast. Tell me what you think made this work so well.”

“What do you think helped him not only stay on the swing, but ask for more?” or “What do you want to try differently next time?”

Mom says “I can see that he is more stable sitting on a small chair at the snack table at school. I am wondering how it would work to have a smaller table and chair at Grandma’s so he could play?”

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Progress information/data collection: Information needs to directly reflect the measurement strategy identified under “How will we as a team measure progress and collect data for this outcome or goal?” Include what was measured and how it was measured. Include information regarding the child's rate of attainment or the child's current skill level, as it relates to the outcome or goal. Document revisions or modifications to strategies as needed or plans for addressing any lack of progress. A review and analysis of this section over time will provide the basis for documentation of progress to support the requirement of ongoing progress monitoring of the outcomes or goals. Data should be presented in a manner that is understandable to parents and caregivers and describes progress in specific, functional terms.

How did the team measure progress and collect data for this outcome/goal?

Examples of documentation

As appropriate, document: What was measured?

How it was measured?

When it was collected?

Who collected the data?

Within what routine or activity?

Mary (Who collected – interventionist) used 5 (frequency count – how) different gestures (what) today (during session - when) while mom was changing her diaper (routine/activity).

Mary used 5 different gestures today while mom was changing her diaper.

Joe responded to the small portions at snack by requesting “more” 5 times.

Latoya walked across the living room using the push cart (5 ft.)

Mom reported that Cody made a choice by reaching after she waited for a response about ½ of the time.

Plans for next session and opportunities for practice: This section is to be used to capture the early interventionist and the family or caregiver’s plans for the next session and follow up. Include activities the parent or caregiver can do between visits to enhance the child’s progress and learning and participation in everyday activities.

Next week we’ll continue with Aiden increasing opportunities to make his wants known. This week he requested more at snack time. Dad suggested having him practice when they go to McDonalds on Fri.

Zoey was able to step down from the stairs today. Next week we’ll meet at the park and have her practice on the stepping stones by the slide.

Continue with ball play but practice outside with dad and the dog. Take time to gain his attention by calling his name and looking to him like we did today.

ADDITIONAL GUIDANCE • Write objectively: Remember that the session note is not about you or your feelings. Make sure that your session notes do not reflect any negative feelings or reactions that you have toward the child, other people or events. Try to avoid terms and descriptions that seem judgmental.

• Write clearly and legibly: Be objectively descriptive. It helps you be precise about what you are describing. Try to avoid vague or general terms. Use proper grammar, and be sure that each sentence has proper sentence structure and sequencing of words so others can understand what you are documenting.

• Write what you observe: Documenting the following can be useful information: the child’s appearance, mannerisms, response to situations or events or to the interaction with you or others, intensity of mood, etc.

• Write so others can understand: Your primary purpose is to explain things so others, including family members, can understand what you are documenting. Avoid the use of jargon.

• Write using people first language: When describing a child and referencing their disability, identify the child first, then the disability. The disability represents only one of many characteristics of the person.

Some of the suggestions included above are adapted from the following text: Summers, Nancy (2001). Fundamentals of Case Management Practice. Brooks/Cole Thomson Learning, United States