Walking all over the house PT teaches the parent Suggested to Laswayn exercises to strengthen (mom) ways to modify legs and core muscles living room to allow child to (details of teaching and move around freely, and to demonstrating listed). encourage cruising. (appropriate use of term “encourage”) Self-Feeding of finger OT teaches the parent Brainstorms with parent to foods techniques for playing with identify favorite foods play dough to strengthen appropriate for finger hands and fingers, and feeding. Assists parent improve eye-hand with positioning and coordination. presentation of foods in high chair. Use of words to SLP teaches parent how to Coaches parent on naming communicate isolate and emphasize objects in the child’s specific early developing immediate environment speech sounds when using single words, clear looking at books with the speech, and drawing child. child’s attention to the object. Only strengths It is important to build on a child’s strengths, and to help parents – identify and value the strengths of their child. Your progress notes must also describe increments of child progress, and the steps you are taking to build on strengths to correct deficits and address needs. Poorly documented Well documented Trig can sit up on his own. Will continue Trig can sit up on his own but has working on trunk strength. difficulty staying upright for more than a few seconds. Showed mom how to use cushions from the sofa for added support as we work toward strengthening his back muscles. Narrative reflects only what the child did Child progress and the child’s – responses to intervention are an important component of documenting services. Too often, however, progress notes consist only of a description of what the child did during a session, leaving out the coaching and instructions to the family or caregiver, attention to family routines and the skilled, professional service.
Walking all over the house PT teaches the parent exercises to strengthen legs and core muscles (details of teaching and demonstrating listed). Suggested to Laswayn (mom) ways to modify living room to allow child to move around freely, and to encourage cruising. (appropriate use of term “encourage”) Self-Feeding of finger foods OT teaches the parent techniques for playing with play dough to strengthen hands and fingers, and improve eye-hand coordination. Brainstorms with parent to identify favorite foods appropriate for finger feeding. Assists parent with positioning and presentation of foods in high chair. Use of words to communicate SLP teaches parent how to isolate and emphasize specific early developing speech sounds when looking at books with the child. Coaches parent on naming objects in the child’s immediate environment using single words, clear speech, and drawing child’s attention to the object. Only strengths – It is important to build on a child’s strengths, and to help parents identify and value the strengths of their child. Your progress notes must also describe increments of child progress, and the steps you are taking to build on strengths to correct deficits and address needs. Poorly documented Well documented Trig can sit up on his own. Will continue working on trunk strength. Trig can sit up on his own but has difficulty staying upright for more than a few seconds. Showed mom how to use cushions from the sofa for added support as we work toward strengthening his back muscles. Narrative reflects only what the child did – Child progress and the child’s responses to intervention are an important component of documenting services. Too often, however, progress notes consist only of a description of what the child did during a session, leaving out the coaching and instructions to the family or caregiver, attention to family routines and the skilled, professional service.