Notes are a concise summary of what intervention took place with the provider, parent and child, and briefly descriptive of parent and child response. Notes provide a record of events and allow PIC to bill for intervention services.
Providers notes interventions completed with parents, or service that is coordinated for the child. Daily notes are completed ideally on the day the service is provided, or by the end of the work week. Notes must be submitted within 7 days of services delivered.
Each of the following RainTree tabs will be completed with information and each answers a question.
- Subjective: Who was there, for what activity and where the meeting took place?
- Example: Met with child, parent and grandparent in family home for EI services. Etester Test, SLP was also present this day for consult.
- Goal: What occured; what did the provider do?
- Select appropriate goal and describe the intervention that was applied.
- Document strategies and, the child's response. Include role-modeling, coaching, feedback, reflection or joint planning that took place within daily activities and routines.
- Use verbs such as modeled, coached, instructed, guided (see list below).
- Only pair the words encourage and suggest with the description of the intervention that was applied. It is important to demonstrate that a treatment was delivered, demonstrated and practiced during the session
- What did the parent do? Document what the parent did with the strategy modeled during the visit.
- Make sure to CELEBRATE somewhere in your note.
- Example of note: DS modeled the use of hand-over-hand instruction with child to sign ‘more’ during snack to request for more portions with caregiver. After demonstrating, instructed mom how to use signs, and offered additional instruction on how to use signs, introduce new signs, and which might work in their situation to start. Mom enthusiastically signed and child used sign for ‘more’ this day after only minimal prompting, and provider celebrated child progress.
- Example of how to note when most of the session is spent with parent in conversation rather than hands on intervention, role-modeling or demonstration: Discussed with parent the stress of sleepless nights and difficulties resulting from those concerns. Problem-solved and parents agreed to use informal supports. Provider also offered additional resources and offered feedback that aligns with parent current strengths and preferences including: food bank, therapists in community and stated would reach out to team for additional resources and get back. Parent will follow-up on referrals as planned.
- Charges: enter clock times in the appropriate box for the services delivered. Providers cannot have overlapping charges, except where using FSC. Aside from FSC, providers must divide the time based on what they did. Where there is a single provider, clock times may not overlap at all.
- Plan: at minimum checkmark appropriate radio button, and if needed, any additional plans unless already listed in the goals section.
Documentation Verbs
Coaching/Intervention: Implemented, applied, instructed, guided, activated, coached, practiced, refined, prepared, used anticipatory guidance, informed, incorporated, pointed out, highlighted, referenced, reinforced, modeled, expanded upon, demonstrated, identified, built upon, reflected and showed, explained, adapted, educated, advised, formulated, equipped, constructed, directed
FSC: facilitated, coordinated, collaborated, supported, shared, provided, scheduled, partnered, discussed, introduced, arranged, navigated,