Notes

Daily Progress Notes: Purpose, Compliance, and Person-Centered Approach

Daily Progress Notes are essential documentation used to record the supports and services provided to each individual. These notes serve as a comprehensive record of an individual’s progress, daily experiences, challenges, and any changes in their needs or well-being. By maintaining thorough documentation, staff members can track trends over time, recognize patterns, make informed decisions regarding necessary support adjustments, and maintain an accurate history of care. This practice is crucial for ensuring individuals receive consistent, high-quality support tailored to their evolving needs.

Why Daily Progress Notes Are Mandatory

Daily Progress Notes are required to maintain strict compliance with state and federal regulations, including Medicaid, DBHDS, and HCBS requirements. These notes serve as verification that services are delivered according to the Individual Service Plan (ISP) and that individuals are receiving the person-centered supports they require. Proper documentation is necessary for audits, funding approval, and quality assurance purposes. Without detailed and timely documentation, services may not be billable, and compliance with necessary regulations may be jeopardized. Furthermore, accurate record-keeping ensures that any modifications to an individual’s care plan are justified and backed by documented evidence, allowing for the best possible support strategies.

Completion Requirements

• Who Writes and Approves the Notes?
  Direct Support Professionals (DSPs) are responsible for writing Daily Progress Notes for the individuals they support. These notes must be accurate, thorough, and reflect the person-centered approach to care. Providers and House Managers are responsible for reviewing and approving the notes written by DSPs daily to ensure accuracy and completeness. Additionally, Program Managers will review and approve notes submitted by Providers and House Managers to ensure compliance with all documentation standards. In the case of Community Engagement (CE) services, the CE Manager is responsible for reviewing and approving CE notes.

• Who Checks for Completion?
  Providers and House Managers are responsible for ensuring that their staff complete Daily Progress Notes daily and that none are missing. They are expected to routinely check for accuracy, completeness, and the timely submission of all documentation. If gaps or inconsistencies are identified, they must be addressed immediately to ensure compliance with internal policies and external regulations. House Managers play a key role in maintaining accountability among direct support staff.

• When Must They Be Completed?
  Daily Progress Notes must be completed on the same day the service is provided, after each shift. This ensures that documentation reflects real-time accuracy and accountability. Completing notes within this timeframe prevents delays in reporting essential information, reduces the risk of errors or omissions, and ensures that all services rendered are properly recorded and accounted for. Late documentation can lead to service discrepancies and potential regulatory issues.

• Person-Centered Approach
  These notes must reflect person-centered care, meaning they should document an individual’s experiences, preferences, and choices rather than merely listing the tasks performed by staff. Progress Notes should highlight personal achievements, challenges faced, and any changes in the individual’s support needs in a way that acknowledges their voice and autonomy. This approach ensures that individuals receiving care are actively involved in their support planning and that their daily experiences are accurately and respectfully represented. A person-centered focus not only enhances the quality of care but also upholds the dignity and independence of those receiving services.

Parts of the Note and How Staff Use Them

Individual’s Name and Date – Ensures the note is assigned to the correct person and recorded on the appropriate date.

Start & End Times – Provides accountability by documenting when services were delivered, ensuring an accurate log of staff interactions and interventions.

1. ISP Outcomes Addressed This Shift – This section is where staff will only select the outcomes the individual worked on for the shift worked. If the outcome wasn't relevant, then "no" will remain in the "Worked on Desired Outcome... box." If "yes" is selected, then a "Progress Note" will be entered. It has to be person-centered, at least one paragraph, and detailed.

2. Activities & Supports Provided – Details the tasks performed during the shift, such as:

   • Activities & Engagement

   • Health & Safety

   • Behavioral Support (If Needed)

3. Risk Awareness & Monitoring – Documents any identified or potential risks observed for the shift, and gives staff the option to check specific risks and give notes on any concerns observed. In this section, you will select if an incident report was completed, if relevant.

4. Logs & Incident Tracking – Tracks if there was a medical appointment, and any required daily logs for Bowel Movements, Vital Signs, Hydration, Skin Checks, and Seizures.

5. End of Shift Summary – Provide a brief summary of the individual’s overall condition and any concerns for the next shifts.

6. Staff Signature and Approval – Verifies that documentation is complete, accurate, and reviewed by the appropriate personnel. Staff should sign immediately after completing their notes to ensure accountability and compliance with documentation standards. The "Select Approver" will be your manager - DSPs will select the House Manager or Provider, or Day Support/CE Manager; Providers & House Managers will select the Program Manager for their home. CE/Day Support Managers will select the Program Director.

The Role of Daily Progress Notes in Care Improvement

Beyond meeting regulatory requirements, Daily Progress Notes serve as an essential tool in continuously improving the quality of care. They allow care teams to identify trends in behavior, health conditions, and service effectiveness over time. By closely monitoring documentation, staff can make necessary interventions to address emerging needs, adjust support strategies, and provide timely recommendations for additional resources or modifications to an individual's care plan. These notes also enhance communication among staff members, ensuring that all team members are informed and aligned in delivering consistent support.

Additionally, progress notes contribute to the individual’s long-term well-being by ensuring proactive responses to changes in health or behavior. For example, regular entries regarding meal intake, mobility, or emotional well-being can help identify early signs of medical concerns that may require intervention. Documenting social engagement and behavioral observations allows for better tracking of emotional and psychological progress, leading to tailored support strategies that enhance quality of life.

Daily Progress Notes are more than just a regulatory obligation—they are an indispensable component of delivering high-quality, individualized care. When completed with accuracy, timeliness, and a focus on person-centered principles, these notes enhance the overall effectiveness of care and ensure that individuals receive the support they need to thrive.

Lauris Documentation Support: Writing Person-Centered Notes

If you are unsure how to word your note in Lauris, reach out to your Program Manager. Documentation is not just a record of activity—it is a critical tool in supporting each individual's progress, communication, safety, and service outcomes.

What Should a Person-Centered Note Include?

All notes must be based on your firsthand observations during the shift. Each entry should reflect the individual’s experience and your support in a clear and detailed manner. To meet expectations:

• Every note must contain more than one sentence. Each sentence should be spell checked and grammatically correct.
  One-sentence notes are never acceptable, regardless of shift type or individual activity level. One paragraph is the minimum for a person-centered note.

• Use complete sentences in past tense. Avoid bullet points or incomplete phrases.

• Maintain a professional and objective tone. Never use casual language or slang.

• Clearly reference the individual’s ISP outcome(s) when applicable.

• Describe the support you provided—physical, verbal, or emotional—and how the person responded.

• Include any notable events, changes in behavior, incidents, health concerns, or safety interventions.

• Complete the End of Shift Summary section thoroughly.

A strong note should describe what the person did, how you assisted them, and how they reacted. It should show evidence of engagement, progress, or patterns that matter for their wellbeing and planning. Avoid vague or non-specific statements like "helped with chores" or "had a good day" unless they are followed with context and relevant detail.

Examples of vague documentation:

• "Fred watched TV."

• "Fred went on an outing."

• "Fred did chores."

Improved examples:

• “Fred watched a full episode of a nature documentary about marine life. He asked several questions about whales and jellyfish, showing engagement and curiosity throughout. This supported his outcome of building focus during leisure activities.”

• “Fred participated in a community outing to the public library. He used the online catalog to find books about healthy recipes and asked staff for help locating them. This activity directly supported his outcome of increasing independence in meal planning.”

• “Fred completed daily household responsibilities with staff support. Tasks included sweeping the hallway, folding clean laundry, and wiping down kitchen counters. Staff provided minimal prompts, and Fred expressed pride in helping to keep his home clean.”

Best Examples (Full Paragraph Format):

1. Fred spent the afternoon watching a documentary on wildlife conservation as part of his leisure activity. Throughout the program, he remained focused, asked several relevant questions, and commented on the importance of protecting endangered species. Staff used the opportunity to reinforce Fred’s outcome of increasing attention span and staying engaged in structured activities. At the end, he shared that he enjoyed learning something new and wanted to watch more programs like this in the future.

2. Today, Fred participated in an outing to the local library, where he independently navigated the building with minimal support. He used the public computer to search for books about baking and located two cookbooks with assistance from staff. This activity aligns with Fred’s outcome to build skills in independent living and explore meal preparation. Fred was proud to check out the books using his own library card and stated he was excited to try one of the cookie recipes at home.

3. During the afternoon, Fred engaged in household cleaning tasks, including folding towels, wiping kitchen surfaces, and vacuuming the living room. Staff provided gentle reminders and used a visual checklist to support completion. Fred followed through with all tasks and responded positively to encouragement, stating he liked how tidy the room looked afterward. This activity directly supports his outcome of building independence with daily living skills and participating in the upkeep of his environment.

Documentation When the Outcome Is Not Applicable (Night Shift)

Night shift documentation is equally important as daytime documentation and must follow the same standards of professionalism and accuracy. Even if the individual is asleep for most of the shift, you are still expected to document clearly and fully in the following two areas:

1. Supports Provided
   Example:
   Fred received overnight support from staff, who conducted hourly safety checks to ensure his well-being. He remained asleep from approximately 10:30 p.m. to 6:45 a.m., and no concerns or medical issues were observed during the night. Staff ensured that Fred’s environment stayed quiet and comfortable to support uninterrupted rest.

2. End of Shift Summary
   Example:
   The overnight shift was calm and uneventful, with no incidents or behavioral concerns noted. Fred woke up at 6:45 a.m. and responded well to staff prompts to begin his morning hygiene routine. He completed his tasks without hesitation and appeared well-rested and in good spirits as the day began.

Even when the ISP outcome is not addressed due to sleep, your documentation must still include:

• Any sleep disturbances

• Medical or behavioral events

• Interactions, repositioning, or assistance provided

• Changes in sleep patterns over time

Night documentation is used by Program Managers, guardians, and medical professionals to identify patterns that affect overall health and service delivery. Do not minimize its importance.

Key Reminders for All Shifts

• Do not copy and paste from other staff notes. Each note must reflect your own direct interactions with the individual during your assigned shift. Even if your observations seem similar to others, the language must be your own. Copying notes can lead to documentation errors, non-compliance, and loss of credibility.

• Do not write vague or generic statements. Be specific about what occurred and provide enough context that anyone reading your note could understand exactly what happened. For example, instead of writing “assisted with hygiene,” write “Prompted individual to brush their teeth and wash their face; they followed instructions with minimal redirection.”

• Avoid assumptions. Do not document information unless you directly observed it or were directly involved. If you arrive mid-task, only document what occurred while you were present. Assumptions, even if well-intended, can lead to inaccurate records and miscommunication.

• Use person-first language and write respectfully and professionally at all times. This means referring to the individual as a person first, not by a diagnosis or behavior. For example, say “individual who uses a wheelchair” instead of “wheelchair-bound.”

• Avoid labeling individuals by behaviors, diagnoses, or functional levels. Focus instead on describing what the individual did, how they were supported, and how they responded. Labels like “noncompliant” or “manipulative” are subjective and should never be used in documentation.

• Always cross-reference the individual’s ISP under Active File → Residential Services or Community Engagement to ensure your documentation reflects their personal goals and service outcomes. If an outcome is not addressed in your note, be sure to explain why (e.g., not applicable during overnight shift).

• If you're unsure what to write, or whether your note meets expectations, contact your House Manager or Program Manager before submitting. Seeking support proactively helps prevent errors, ensures accuracy, and promotes professional growth. It is better to ask questions than to submit incomplete or noncompliant documentation.

Documentation & ISP Training

Weekly Activities (Required Documentation for Group Home & Sponsored Home Services Only)

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