PROGRESS NOTES Rachel CoatesCampbell LCSW FYAP Lead Counselor

PROGRESS NOTES Rachel Coates-Campbell, LCSW FYAP Lead Counselor – Northwest January 20, 2016 Best Practice

CAA Progress Notes • CAA Progress Notes are mandatory • CAA Progress Notes are part of a ‘Pupil Record’ • CAA Progress Notes are confidential and should be protected, whether they are electronic files or hard copies • CAA Progress Notes are to document significant dates, people, information as well as work/progress towards the ISP goal(s) • CAA Progress Notes are to remain general and neutral

CAA Progress Notes Should Include: • Your history of intervention, starting with efforts to complete the CAA • What are you doing? • Why are you doing it? • What was the outcome? • When documenting student contacts you should be referencing the connection between what you are doing and the student goal (ISP) • Your Initials after each entry: ‘R. Coates’

Progress Notes: Common Errors • Use proper grammar and spelling • Start your notes with documentation on your start of the CAA work • Write out words rather than acronyms or abbreviations • Use last name and professional title • Avoid writing in first person • At the end of each progress note, use first name initial and last name (ex: R. Coates) • If you document something like a ‘crisis’ be sure to indicate what the follow up plan is and then a follow up note indicating the status

CAA Progress Note: Example • 9/25/15 Reviewed student’s records to begin completing the CAA and ISP forms. Emailed Ms. Alfaro, CSW to introduce self and FYAP services/program and to request information to complete the CAA. While reviewing the student’s attendance and grade records, it was noted that there is no open court case in MISIS. Therefore, Ms. Alfaro CSW was emailed to request status on the case. Awaiting a response. R. Coates • 9/30/15 Second email request was sent to Ms. Alfaro CSW regarding if case is voluntary or closed. R. Coates • 10/5/15 Final attempt in contacting CSW by telephone to confirm if this case is closed. According to MISIS there is no open court case. Checked SITS and no case indicated. Student is not found on new Data. Match list. Further work suspended at this time due to no open court case. R. Coates

CAA Progress Note: Example • 9/1/15 Reviewed academic records to begin CAA. Met with student’s teacher and Principal to introduce self and FYAP program. Discussed any student concerns or needed supports. R. Coates-Campbell • 9/1/15 Emailed DCFS CSW, Ms. Alfaro to introduce FYAP service and confirm that student has an open court case as well as who the ERH is. R. Coates-Campbell • 9/5/15 CSW, Ms. Alfaro emailed back and confirmed court case and academic concerns for student. FYAPC will now follow up with caregiver. R. Coates-Campbell • 9/5/15 FYAPC called caregiver, Ms. Pam Smith to introduce self and FYAP services. Discussed any concerns the caregiver is having regarding academic progress of the student. Shared recent report card information and teacher concerns. Caregiver would like a referral to tutoring. Caregiver concerned about student’s social skills. FYAPC to provide caregiver with consent for services in order for student to participate in a school-based social skills group. R. Coates-Campbell • 9/6/15 FYAPC mailed consent form for social skills group. R. Coates-Campbell • 9/10/15 Consent was received. Student was observed at recess to assess social interactions. After recess met with student individually, discussed meeting regularly to work on ‘friendship skills’. Student agreed. Discussed a goal. Gave student a referral for tutoring. Completed the CAA. Will meet with student in one week. R. Coates-Campbell

Personal Notes: What’s the Difference? • Personal notes are optional • Personal notes are a reflection of longer thoughts, reflections and observations • Personal notes are to be kept separate from CAA Progress Notes and out of a public forum such as your CAA electronic file • If supervising an intern, Reflective Learning Tools or Process Recordings are considered personal notes.