Embedded Files
How do I ensure my payroll billing matches the session notes?- see video
Create a session note for each visit. Here are 2 options to create a session note in Provider Soft on your desktop:
Post a single session (Watch this video for details)
Populate a session (Watch this video for details)
Use the current State form for your session notes (already set for you in Provider Soft). Complete all fields of the document clearly, correctly and in pen (if hand-written). Include the child’s BSU # on every session note. Changes to paper notes should follow DPW standards. Indicate the goal number on each session note (and write enough text to unmistakably identify the outcome or goal). Time in/out should be clearly noted. Session note guidelines indicate to round your time down when indicating units. Document Routines, Routines and more Routines (don’t just note “daily routines”—be specific!). Make the notes family friendly—do not use technical terms (i.e., use “child” instead of “patient”, use “legs” instead of “lower extremities”). Be specific in every section. If you are working with a Spanish speaking (only) family, session notes should be in Spanish.
Each of the elements on the form must be filled out on the note, and it must be signed by a parent. DO NOT have parents sign a blank note.
If you are in a daycare environment, make sure that your session note is written for the teacher and for the parents (for carry-over at home) and signed by the caregiver. Try to provide a copy to the teacher and the parent. Please watch this video link for additional tips for the daycare setting.
You MUST document a “no show” in Provider Soft with a unique session entry. Be sure to indicate the reason why (ex., parent did not answer the door, cancellation on part of staff or family, etc). Follow our policy in terms of providing the family with a duplicate copy of the policies. If you are getting a lot of no shows, keep scheduling of your daycare children and flexible families to the last minute to possibly fill in the gaps. After TWO No Shows, please contact the Service Coordinator.
If your service frequency veers from the authorized service plan for any reason (missed session, vacation, no show, holiday, etc.), there must be an explanation.
If you are responsible for more than one goal, please be sure to complete a separate session note for each goal.
In the event your goal is met and you begin working on a new goal, be sure to state that in the session note so that it clearly reads like a book, and it may also be mentioned in the communication log as you will coordinate with the SC when this occurs.
A session note should tell the story of your visit. Feel free to take the whole 10-15 minutes of each session telling your story so you can leave it for the family to review.
Logging Missed Sessions (or other information) on the Provider Soft Communications Log
Spanish session note: Session notes are not required to be translated and a plan has been put in place to support our Spanish speaking families. If a bilingual therapist is serving the family, the session note is to be provided to the family in Spanish. If a therapist is serving the family with an interpreter, the English session note is to be provided to the family with no translation required.
If needed, hard copy session notes can be picked up from Ann's house. Hard Copy Session Note Inventory
Electronic Session Note (Google doc); Electronic Session Note (PDF); Electronic Session Note (Word)
EI Session Note Annotated Guidelines
Staff meeting recording/tutorial of new session note Passcode: #?X8R8XG
EI Session Note Training Video (State form)
Session Note Sample: OT (includes follow up session)
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