Progress Notes/Service Delivery Log

Progress Notes/Service Delivery Log (⬅print link to print form)

Agencies may have their own specific guidelines for writing progress notes that reflect activities conducted with a client or on their behalf. Progress notes should tell a story. For instance, if there is a two-month gap in notes, the person reading the chart should be able to understand the reason for the gap in services. Also, note writing should be simple, because we won't want office personnel or the person assigned to reading those notes to spend more time than necessary working on paperwork, however, they should include the location of the service, duration of service and description of services provided.

Extra Note Sheet

The following words and terms, when used in these billing guidelines, have the following meanings unless the context clearly indicates otherwise:

ADLs or activities of daily living — Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing and transferring

Billable activity — An activity for which a service claim may be submitted for service components and subcomponents listed in Section 3100, Applicable Service Components.

Calendar day — Midnight through 11:59 p.m.

Calendar month — The first day of a month through the last day of that month.

Calendar week — Sunday through Saturday.

Calendar year — January through December.

CFC PAS/HAB or Community First Choice Personal Assistance Services/Habilitation — A state plan service that consists of:

(A) personal assistance services that provide assistance to an individual in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including:

(I) non-skilled assistance with the performance of the ADLs and IADLs;

(II) household chores necessary to maintain the home in a clean, sanitary and safe environment;

(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and

(IV) assistance with health-related tasks; and

(B) habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:

(I) self-care;

(II) personal hygiene;

(III) household tasks;

(IV) mobility;

(V) money management;

(VI) community integration, including how to get around in the community;

(VII) use of adaptive equipment;

(VIII) personal decision making;

(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and

(X) self-administration of medication.

Service Delivery Log  Forms 4122

Purpose: Form 4122 is used by Department of Aging and Disability Services (DADS) staff and Home and Community-based Services (HCS) Waiver program providers to document a service claim for the host home/companion care service component.

ADLs- Activities of Daily Living are defined as "the things we normally do such as feeding ourselves, bathing, dressing, personal hygiene, eating, meal planning, and housekeeping. A number of national surveys collect data on the ADL status of the U.S. population. While basic definitions of ADLs have been suggested, what specifically constitutes a particular ADL for each individual may vary. Adaptive equipment and devices may be used to enhance and increase independence in performing ADLs.

*DADS Texas Direct Care Staff Part I

*DADS Texas Direct Care Staff Part II

*DADS Texas Direct Care Staff 

Developmental and Improve Independent Living Skills - includes activities of daily living and skills development training objectives not otherwise listed.

Community Integration - taking the individual on outings such as out to eat, movies, church, et cetera.

Develop Socially Valued Behaviors - anytime the staff recognizes that the individual is choosing the correct behavior or response to a situation, is acting appropriately in public, or anytime staff is teaching the individual positive social behavior.

Use Of Natural Resources - staff assists the individual along with outside of the home such as friends or family.

Participates In Leisure Activity - the individual socialized with other housemates or visitors.

IP Skill Development - check/initial this anytime you work with the individual on their objectives or any skill development listed in the individual's Implementation Plan.







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