6-25-08

I came in an hour late today, so when I arrived the consumers were already playing bingo. Once bingo was over Amanda informed me about a consumer who was having some difficulties recently. She wanted me to go over coping skills, warning signs, and ways to handle if he had outbursts. Amanda made a notebook for him where he could enter such things, and so that he could use the notebook as a coping skill to write in at times when he was having problems. He decided to leave early this day since because of his problems, so I only had a short 10-15 minutes to go over these things with him.

Pam taught me about how they use a progress note for consumers, called the rehabilitation services progress note. On it they list the consumer’s stressor or extraordinary event for needing the note, then any behavioral strengths the consumer exhibits. They have selections for language/motor activity including restless, slurred speech, pacing, and agitated; selections for mood/affect including euphoric, anxious, angry, apathetic, and appropriate; and selections for thought/perceptions including hallucinations, paranoid, obsessive, and delusions. Then one can select case management (CM) or Activities of Daily Living (ADL) and described items in either category such as contacted, informed, facilitated, monitored, or obtained for CM, and assisted, guided, reminded, demonstrated, directed, or trained for ADL.

Next the writer describes in detail what all happened and was gone over. This is done through PIRP: Problem, Intervention, Response, and Plan (of Action). The writer always follows this when writing these notes. Next the administrative items are filled in such as the writer’s credentials, billing codes, date of service, times, duration, consumer name and clinical record, and the consumer’s goal and objective that is being worked on.

After lunch Amanda helped me get the necessary tax information that is needed for the donation letter I had to write. She gave me information I needed to write the letter, such as Cummins’ value statement and mission statement. She left me in the back to work on the letter while she ran the rest of the groups for the day.