Transcript Test Title 1 - Spokane County, Washington

Charting to the Person-Centered Plan
Writing Service Notes
• There are numerous acceptable formats for best practice
Service Note documentation. More common models (and
their associated acronyms) include:
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S-O-A-P: Subjective, Objective, Assessment and Plan
P-I-R: Problem(s)-Intervention(s)-Response(s)
G-I-O: Goal(s), Intervention(s), Objective(s)
G-I-R-P: Goal(s), Intervention(s), Response(s), Plan
• The GIRP model can be helpful as it directly links the note
to the content of the plan itself
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Charting to the Person-Centered Plan
Service Note Structure
• What goal/objective were you working on?
• (from IAP)
• Goal(s)/ Objective(s)/ Intervention(s)
Addressed as Per IAP…
• What was the intervention?
• (reviewed, coached, prompted, assisted,
encouraged, etc)
• How did the consumer respond?
• (use feeling words and/or action words)
• Response to interventions…
• What are the next steps?
• (next visit, client will, client plans to…)
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Charting to the Person-Centered Plan
G - Goal(s)
• Describes the individualized goals and objectives being
worked on
• Why the consumer is participating in this particular service
at this particular time.
• Comes directly IAP
• Consistent with the quality definitions of goals/objectives,
this aspect of the note should refer to the individual’s
hopes, preferences and “desired outcomes”
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Charting to the Person-Centered Plan
I - Interventions
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Describes the services you are providing to assist with…
• Reducing/eliminating barriers (e.g., symptoms, behaviors/functional
impairments) to the person’s goal.
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Are described in sufficient detail to clarify to all readers (including auditors for
billing):
• What was provided
• Why it was provided
• When it was provided
• Where it was provided
• Who provided it
• How it was provided
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If you are a rehabilitation provider, just as in the IAP interventions, your notes
should incorporate the active SKILL-BUILDING language of psychiatric
rehabilitation,
• i.e., NOT only observe and monitor… but based on what you observe, how
do you then INTERVENE to build skills by teaching, coaching, practicing,
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demonstrating, etc.
Charting to the Person-Centered Plan
R – Response
• Describes the consumer response to the interventions provided, i.e.,
is the person able to benefit from skill-building in order to make
progress toward the objectives on the IAP
• What aspects of the task have been mastered? What still needs
to be developed?
• Often includes quotes from the consumer re: how she/he is feeling
about this particular area of work and pace of progress toward IAP
goals and objectives
• May include observations of the consumer’s affect, tone of voice,
appearance, behavior thought process, and/or attitude
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Charting to the Person-Centered Plan
P – PLAN/Next Steps
• Describes the plan for continued services and describes what, if any,
modifications need to be made to interventions and whether any
referrals or new services are recommended.
• It’s important to not only describe the process, but also to identify what
the consumer decided to do.
• If problem-solving, which response did the consumer choose?
• If discussing, where did the conversation end up?
• What next? (on the part of the consumer as well as the
rehabilitation practitioner).
• The “P” aspect of Service Notes is often missing or neglected. It is
particularly critical to detail the plan moving forward in circumstances
where a person is struggling and you have concerns about their
functioning or safety. Note explicitly how you have increased contacts
and supports; how you have consulted with supervisors and/or clinical
providers; and how you planned with consumer for actions to be taken
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in the event of a crisis.
Charting to the Person-Centered Plan
Common Quality Errors in Service Notes
• Fail to “chart to the plan” - Lets assume objectives on a plan are around
increased independence with medication self-administration skills and
increased skill in navigating public transportation
• Met with Joe today at my office. He said he wasn’t doing so good.
He complained about his landlord not fixing his hot water heater so
we talked about ways to get him to take action. He is also very
stressed out because he got a letter saying his SSI check is going to
be reduced because he’s getting food stamps now. I told him I’d look
into the SSI issue for him and get back to him…
• While there are times where we need to go with what the person brings
in and address the priority of the moment, be cognizant of the need to get
re-focused on the specific goals and objectives noted in the IAP
• Alternatively, the notes may chart to the plan but may be incomplete or
fail to adequately capture the active skill-building role of the rehab
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practitioner