EARLY INTERVENTION SESSION NOTE

Adapting to Routines Sharing your Expertise

Communicating and Collaborating

Guidance for Writing EI Session Notes

• You must use the state session note.

• All items MUST be completed. • Documentation through a session note is needed for every session as well as for visits planned and not

delivered, regardless of the reason.

• Parent /Caregiver signature is needed for every note. • Taking notes home to write=forgetting as well as not following

the mandate.

Breaking the form down The Basics

Date of service Time in Time out Units:(15min=1unit)

Name of child Provider Agency(CCEI) The Children Center for Early Intervention

Type of Service(speech, OT, PT, Special Instruction)

“Other”(Vision, hearing, audiology, behavior)

Type of session:

INITIAL:

ONGOING:

OTHER: (last session?)

Location= Where?

Home

Grandmother’s home

Preschool

Community location(market, Little Gym, etc.)

Progress......

Outcomes

Activities

Routines

Strategies

Suggestion

Plans for next

session

Date Collection

Breaking it Down (continued)

INITIAL SESSION By mandate, we are to begin services within 14 days of the IFSP date. If this is not possible you must note the reason on the initial session note: Parent unable to be reached.

Awaiting medical forms (i.e.: Physician’s script for PT

services).

Therapist availability; Family availability, etcetera.

Clarification on responding to question #1

PROGRESS SINCE LAST SESSION Including Parent Feedback

Regarding Type of Session:

• If it is the initial session, write “Initial Session” again here and note if there is a reason for a delayed start (beyond 14 days).

• If it is an ongoing session, get an update from the parent/caregiver before you proceed with your session and document it.

• You may want to open the dialog with the parent/caregiver with specific statements (some examples follow)…………

Clarification on responding to question #1

Progress since last session…Continued

• “So what changes have you seen since last week.”

• “How has the (floor time) positioning and play been going?”

• “How are you doing with [the strategy] we worked on together last time we met?”

• “Any more spontaneous sounds/words this week?”

• “What has been working for you this week to help her look to the left side more easily?”

• “Have you noticed any improvements in how long she is playing independently?”

• “Fill me in on last week’s doctor appointment.”

• “Are there any new concerns?”

Clarification on responding to question #1 Progress since last session…Continued

• Discuss how strategies from last session are working.

• Ask what other team members are working on.

• Ask about data collection the family was asked to collect, for example…

Distance child was able to creep along floor Number of new words or sounds Duration and frequency of tantrums Time it took to fall asleep

COMPLETE THIS SECTION BEFORE YOU BEGIN THE CURRENT SESSION.

Clarification on responding to question #2

Outcomes/Goals from IFSP to be Addressed

• You must capture the outcome AS WRITTEN

on the IFSP.

• Avoid writing generalizations for goals, such as

Increase play skills

Improve communication

Improve sensory needs

Improve motor skills

You may abbreviate the outcome but it should be

close enough to positively identify the IFSP plan, as well as capture family routines.

Clarification on responding to question #3

DAILY ROUTINES USED

• Notes need to have documentation that services are being delivered within the child/family’s routine(s) or the early childhood setting-routines.

• The activities should be a reflection of a functional part of the day for the child.

• Conversations need to be ongoing regarding the daily routines of the home/classroom.

Clarification on responding to question #3

DAILY ROUTINES USED:

• Playing with toys • Bath/hygiene • Medical/comfort • Dressing related • Community; Family errands • Mealtimes • Books • Songs/Rhymes • Writing/drawing • Morning Routines • Evening Routines

Clarification on responding to question #3 What We Did Today to Address Outcomes…

• Within the routines

• Addressing difficulties • Modeling strategies

• NOTE HOW YOU HAVE INCORPORATED the PARENT/CAREGIVER IN SESSION

• To “BAG” or Not to “Bag” Use resources in the home that can be used to

practice skills after you leave…preferred

Demonstrate what skill you are targeting and how to generalize to other activities and materials in the

home; do not assume that the parent/caregiver can automatically generalize.

Clarification on responding to question #3

What We Did Today to Address Outcomes…. • Clear description of the visit and how you used specially designed

instruction, supplemental aids and program personnel

• Be open to questions from caregiver who might not see the “WHY” of your approach

• Following the lead of the family and child

Be responsive to cultural uniqueness

Learn and adapt to the learning styles of adults in the home/preschool

Clarification on responding to question #3

Strategies used: • Write the best description of the strategies you used:

• Modeling or demonstrating for child

• Giving cues or prompts

• Turn taking

• Offering choices

• Modifying the environment

• Describing or labeling what you are doing

• Adjusting pace by waiting or pausing for response

• Encouraging child to imitate

• Positioning

• AT (assistive technology) including visual supports

• Others might include

Facilitating information for family

Community outreach

Other (be specific)

Suggestions for family to do within routines/activities

• It is very important to provide a few suggested follow through activities, such as…

Looking in mirror and making faces Use of straw to drink thickened milkshakes or yogurt Playing on floor and moving toys from side to side for child to track Putting favorite items a bit out of reach Count number of steps he/she takes Act silly together to increase engagement Walk along perimeter of park Place a new food on his plate and just let it be there Place favorite food in a different container to serve

WHENEVER POSSIBLE, INCLUDE THE ROUTINES AND NATURAL OPPORTUNTITIES IN WHICH TO PRACTICE

Focus on the Strategies Used

• Early intervention services need to be provided in a way to empower the caregiver to support the child in daily activities.

• Pick strategies that best match the learning style of

the family/adult caregiver as well as the child.

• Be sure to give positive feedback to the parent/ caretaker as well as the child.

Clarification on responding to question #5

Plans for Next Session • Revisions to what you are doing to address a lack of

progress.

• Change of family priorities may result in new directions.

• Materials needed by family/therapist.

• Follow through with any resources discussed.

Progress Information to be collected between sessions

• Reflects back to plan, “How as a team will we measure the progress and collect data for

this outcome?”

• Include what you are measuring and how it is to be measured; note additional or adapted ways to measure the progress.

• Make it functional and meaningful to the family.

• Current skill level or rate of improvement related to the outcome.

Name, Title, and Caregiver Information

• Your name, title & signature must be on every note.

• On the first few notes you write, include your

phone # (cell) for families to have

• Parent/caregiver name & signature must be on every note.

What about a missed session?

A session note must be completed for each service mandated on the IFSP. For example, if a child is

mandated for speech 2 times per week then there must be 2 session notes written per week, whether a session was given or missed. Whenever possible , the reason for a missed session should be documented.

If there is a gap in services (3 or more consecutive missed sessions are considered a gap) then a “Three Consecutive Session Absence Form” must be completed and submitted within 48 hours.

Added Guidance

• Write objectively

• Write legibly

• Write what you observe; avoid judgmental information and do not make/write assumptions

• Never diagnose, verbally or in writing!

• Write in a way that others can understand: avoid professional jargon and overly clinical statements.

• Write using “People First” language– Identify child’s first and then possibly the disability, if there is

one, and it is necessary to write that– “Mom” has a name

Session Notes Reflect….

• On your visit!• On progress! • On routines!• On goals and outcomes!• On collaboration!• On involvement!• On YOU!