PERMANENT ONGOING NOTES

Initial Intake Billing first two lines

(I) CC met client, to discuss program. CC and client discussed program requirements and benefits. Please refer to Initial Intake Packet.

(ICP) CC and client met to discuss care plan goals. Please refer to Initial Care Plan.

(PHONE CALL NOTE) CC contacted client to set up home visit for the month. Discussed client schedule and resources gathered.

(BILLING NOTE) CC completed recordkeeping, chart notations, preparation of appointments and client schedule.

VIRTUAL VISITS

CC spoke with client over the phone (due to “Telehealth Ordinance” CC and client discussed

CC spoke with client over the phone (due to “Telehealth Ordinance” CC and client continued to discuss

CC spoke with client’s collateral contact (enter name of collateral contact)  over the phone (due to “Telehealth Ordinance” CC and client’s collateral contact  discussed

CC spoke with client’s collateral contact (enter name of collateral contact)  over the phone (due to “Telehealth Ordinance” CC and client’s collateral contact  continued to discuss

EMPLOYMENT

CC provided and discussed employment resources with client. Assisted in obtaining services to learn about and improve life skills. Helped member identify employment goals and barriers to obtaining or maintaining employment.

Assisted in obtaining services to learn about and improve life skills. CC provided and discussed employment resources with client.

CC provided and discussed employment resources with client.

CC and client reviewed resume templates and conducted mock interviewing practices.

Client and CC spoke about current job positions.

CC spoke to client about interview attire and job readiness.

CC spoke to client about interview attire.

CC provided job resources. CC and client went over current job postings.

CC provided client with job search engines like;

ISSUES CONCERNING CHILDREN HEALTH ISSUES AND/OR HEALTH AND NUTRITION TOPICS

Client concerned about children being “hyper.” Assess knowledge/ understanding about nutrition and infant/child feeding practices and how it affects growth and development.

Assessed knowledge regarding basic child health and development.

CC updated progress notes

Assessed knowledge/ understanding about nutrition and infant/child feeding practices and how it affects growth and development. Encourage establishment of safe behaviors

CC followed up with client about healthy meal prepping. CC provided coupons and menus.

COPING WITH A NEWBORN/POST PARTUM

Assessed knowledge regarding basic child health and development.

CC spoke to client about the pros of breastfeeding. CC went over breastfeeding pamphlet

Assessed interpersonal relationships with the infant/child, her partner, and other family members in the home. Assist in obtaining services to learn about and improve life skills.

Assess knowledge/ understanding about nutrition and infant/child feeding practices and how it affects growth and development. Encourage establishment of safe behaviors

CC and client spoke about growth and development and infant stage.

CC spoke to client about tummy time and joining infant/child while playing.

CC spoke to client about infant sleeping arrangements and SIDS. CC went over SIDS information/pamphlet. CC advised client infant should sleep alone and on back with sheets tucked securely.

LIFE SKILLS

CC spoke to client about prioritizing

CC spoke with client about setting and achieving personal goals

ISSUES WITH NEIGHBORHOOD AND/OR COMMUNITY SUPPORT

CC Assisted with identifying neighborhood activities and community support groups. CC provided local community resources for;

Provided information on community resources/ referrals to other agencies.

PERSONAL SUPPORT ISSUES

Client concerned with the lack of support from family and friends, cc provided resources to; that will enhance family functioning. Assisted in obtaining services to learn about and improve life skills. Encouraged establishment of safe behaviors.

Assessed the member’s self-esteem, assertiveness, and empowerment regarding family planning decisions.

Assess interpersonal relationships with the infant/child, her partner, and other family members in the home.

Assess interpersonal relationships with the infant/child, her partner, and other family members in the home.

EDUCATION

CC provided GED resources. CC spoke to client about long-term short-term goals.

HOUSING

CC provided and discussed the urgency of client’s housing needs.

CC spoke to client about moving arrangements. CC provided mover resources and rates.

CC provided client with house search engine tools like;

RESOURES/TOOLS FOR HOME

Client expressed needs for items in home; furniture, cleaning supplies, cc referred client to Goodwill and completed goodwill voucher through Generation of Excellence Prenatal

CC spoke to client about furniture resources. CC provided resources for discounted furniture.

CC spoke to client about fire safety and changing/checking smoke detector batteries every 6 months.

CC and client went over LEAD pamphlet and conducted a Lead check

CC spoke to client about home cleanliness and prioritizing.

CC and client went over home safety checklist. CC provided checklist to client. CC advised client to place gates in staircase.

PARENTING SKILLS WITH TODDLER/CHILDREN

CC spoke to client about potty training.

CC and client spoke about interpersonal relationships.

CC provided child education class resources.

TRANSPORTATION

CC provided resources for transportation.

CC spoke to client about home safety inside and outside of home.

HEALTHY PRACTICES AND IMMUNIZATIONS

CC spoke to client about Lead testing for child/ren 6 months and older.

CC spoke to client about areas Lead can linger. CC spoke to client about staying Lead free and things that can be done to staying lead free.

CC spoke to client about the importance of immunizations timeframes and keeping doctor appointments.

CC and client spoke about health and development

CC spoke to client about infant milk intake. CC spoke about formula storage n preparation.

BUDGETING

CC and client spoke about money management. CC spoke about writing income and bills down to see where client can save or cut with bills.

Cc provided client with names of coupon support groups on social media and coupon apps for cellphones.

CC spoke to client about couponing and budgeting for household items/food etc.

CC spoke about budgeting and saving.

ABUSE/STRESS/COUNSELING

CC spoke to client about past abuse and counseling. CC provided counseling resources.

CC spoke to client about child support and father absences.
CC spoke to client about living stress free. CC provided exercises client can try for stress.

CC spoke about goals and barriers. CC spoke to client about overcoming barriers.

CHILD CARE NEEDS

CC spoke to client about obtaining daycare services. CC provided local daycares resources.