Progress Notes: The Narrative
G
Goal(s) and Objective(s)
What Goal(s) and objective(s) from the ITP were addressed?
I
Intervention
What were the interventions used by staff?
R
Response
How did the recipient Respond to each intervention(s)?
P
Plan
What is the Plan for the next session?
S
Significant Observations
What are the Significant observations?
The progress note must reference the rehabilitative Goals and objectives as indicated in the rehabilitation service plan addressed in the session. Establish that there is a clear and evident connection between the treatment plan and what is being discussed in the remainder of the progress note.
Document by simply recording the rehabilitative goal(s) and associated objective(s) as it appears on the rehabilitative service plan. This information should be placed before the progress note narrative.